Pregnancy Options Counseling and Abortion Referral Practices Among Colorado Nurse Practitioners, Nurse‐Midwives, and Physician Assistants

Abstract

Introduction Access to abortion is a public health priority. Yet little is known about pregnancy options counseling and abortion referral practices, both essential to timely abortion care, among advanced practice clinicians (APCs; nurse practitioners, nurse‐midwives, physician assistants). Methods Data were drawn from a stratified random sample of Colorado APCs, oversampling certified nurse‐midwives (CNMs), women's health nurse practitioners (WHNPs), and rural clinicians. Pregnancy options counseling and abortion referral practices were described. Weighted multivariate logistic regression models were used to examine associations between participant characteristics and providing options counseling, referring for abortion, and referring to crisis pregnancy centers. Results Of 513 participants (response rate 21%), 419 provided pregnancy testing. Only 201(48%) reported they were willing and able to counsel on all 3 options. Religious or personal objection was the primary rationale for unwillingness to present abortion as an option (63%). However, lack of knowledge was the main rationale for unwillingness (64%) and inability to counsel (79%), whereas institutional barriers fueled inability to refer (59%). Although 53% referred for abortion care, 31% referred to crisis pregnancy centers. Characteristics positively associated with providing options counseling included being a CNM or WHNP (odds ratio [OR], 2.73; 95% CI, 1.32‐5.66), having received options counseling training (OR, 2.84; 95% CI, 1.48‐5.43), and feeling adequately trained on abortion counseling (OR, 6.61; 95% CI, 3.62‐12.08). Characteristics positively associated with referring for abortion included being a CNM or WHNP (OR, 2.27; 95% CI, 1.18‐4.36), having received options counseling training (OR, 2.39; 95% CI, 1.36‐4.22), and feeling adequately trained on abortion counseling (OR, 3.5; 95% CI, 2.00‐6.11). Only provider type was associated with referring to crisis pregnancy centers; CNMs and WHNPs had the lowest odds (OR, 0.29; 95% CI, 0.15‐0.54). Discussion Pregnant patients in Colorado may not receive evidence‐based pregnancy options counseling or abortion referrals. Clinician training on options counseling and abortion referrals is needed.

The Critical Role of Midwives in Safe Self‐Managed Abortion

“…Information about pregnancy identification, early pregnancy loss, and abortion are part of the ACNM Core Competencies, but information about self‐managed abortion is not 35 . Midwives also report some discomfort with options counseling in general and feeling unprepared to do so, in part because of a self‐perceived lack of knowledge around abortion 9 . This is problematic for many reasons, because abortion is a common experience in the United States, but particularly so for self‐managed abortion, which exists outside of the familiar and safe‐feeling structures of health care.…”

“…Legally, many providers may also find themselves in murky or even clearly dangerous waters, because provision of abortion is banned for nonphysicians in 37 states, and many midwives practice in areas that are unfriendly at best to self‐managed abortion and abortion overall 2 . Additionally, midwives may individually find themselves conflicted or in opposition to abortion as a care practice, 9 and this opposition may carry over from direct care provision to information‐sharing. Although information‐sharing does not require participation in abortion by an individual midwife, even broaching the topic may feel legally dangerous or ethically unsupportable.…”

“…This represents an opportunity for both harm reduction (by informing patients about signs of needing further care, eg) and increased patient awareness and understanding of their health care options. However, midwives (and nurses) report having limited knowledge about abortion pills and may therefore be unable to respond to direct questions or to adequately support patients in more safely obtaining self‐managed abortion 9 . This article reviews the need for further patient and community education related to self‐managed abortion, the role of midwives in providing that education, and the ethical issues involved in ensuring equitable access to accurate information as well as the role of that information in reducing potential harm in vulnerable communities.…”

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

“…Studies suggest that non‐comprehensive pregnancy options counseling favors counseling around continuing pregnancy over abortion counseling 22,23 . Such pregnancy options counseling bias can coerce patients into continuing pregnancy, and may in turn lead them to face downstream maternal and infant mortality risks 21,24,25 .…”

“…Studies suggest that non‐comprehensive pregnancy options counseling favors counseling around continuing pregnancy over abortion counseling. 22 , 23 Such pregnancy options counseling bias can coerce patients into continuing pregnancy, and may in turn lead them to face downstream maternal and infant mortality risks. 21 , 24 , 25 Inadequate counseling at the point of initial pregnancy confirmation may also play a role in further reducing patients' trust in medical systems, with implications for pregnancy care and beyond.…”