Early Options: The Medical Abortion Procedure

Early Options - A Provider's Guide to Medical Abortion

This page contains the following sections:

Initial Screening
Counseling
Provision of On-Call and Emergency Services
Follow-up

The provision of medical abortion services involves multiple steps that span the course of several days or potentially a few weeks, depending on the protocol employed and the course of the treatment. Click here to view Figure 1.

As with the provision of all medical services, the patient should be made to feel welcome at the office. Maintaining patient confidentiality and privacy during registration and counseling and throughout the process is essential. A private area should be created in which these exchanges can take place.

After reading this section, you should be able to answer the following question:
What is initial screening intended to do?

Initial Screening
Most commonly, the initial screening will occur on the telephone; however, in some cases it may instead take place during the first patient visit. The staff member performing the initial screening (clinician or counselor) first determines the patient's understanding of her pregnancy options and her genuine interest in terminating her pregnancy.

If the patient chooses abortion, the next steps are to estimate gestational age, review eligibility criteria, and, if the patient appears to be eligible for both medical abortion and vacuum aspiration, to present basic information about both methods. The description of the medical abortion option should include an explanation of the number of visits required and of the need for vacuum aspiration if the medical procedure fails.

The provider should also address the costs of treatment during this preliminary discussion and verify third-party payer coverage before the first visit to the medical facility, if possible. Much of the patient education included in the initial screening can also be provided in a taped telephone message, or in an audiotape or videotape. (See Module 3, "Counseling for Medical Abortion," for more detailed coverage of counseling and patient education.)

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After reading this section, you should be able to answer the following question:
What should the counseling session for medical abortion accomplish?

Counseling
The time required for patient education and counseling varies according to the needs of the specific patient and the information covered during the initial screening process. Even if the initial screening included a great deal of information, the counselor (or clinician/counselor) must allot ample time to review the abortion protocol and what to expect, address the patient's questions and concerns, and obtain informed consent.

Women choosing abortion with mifepristone and misoprostol must receive a copy of the Mifeprex® Medication Guide and the Patient Agreement required by the FDA. After the patient reads these materials and has her questions answered, both the patient and the provider must sign the Patient Agreement. The counseling session is also an optimal time to broach the subject of post-abortion contraception.

All counseling must be conducted in private. Because of the time involved in adequately counseling and preparing patients for medical abortion, it is reasonable for the assessment of gestational age, either through physical or ultrasonographic examination, to be performed before counseling if there is any doubt about the patient's eligibility based on estimated gestational age.

Because medical abortion is a relatively new option in the United States, patients considering this service may require more counseling than those contemplating vacuum aspiration. In a survey of providers, slightly more than half of providers said that counseling for medical abortion took between 30 and 60 minutes compared to 15 to 30 minutes for surgical abortion.⁸ However, the same survey demonstrated a rapid learning curve with medical abortion, with providers stating that once they became familiar with the process, they became more comfortable and faster. Therefore, the time required to counsel medical abortion patients should decrease as providers gain more experience with the procedure. Increasing public awareness of medical abortion is also likely to decrease the amount of time needed for patient counseling.

Interestingly, a productivity survey of Planned Parenthood centers that offer abortions found that providing medical abortion takes less total staff time overall than providing surgical abortion (an average of 4.2 total staff hours vs. 5.4 total staff hours).⁹ Another study of 10 diverse practice settings providing medical abortion in the U.S. found that staff time spent face-to-face with each patient over the course of the medical abortion process ranged from 37-130 minutes.¹⁰ Like the Planned Parenthood productivity study, this relates to time spent during the whole process rather than simply during counseling.

Thorough counseling that addresses the patient's questions and concerns will likely result in fewer calls for clarification and reassurance later in the process.⁸ Since women may forget some of the instructions communicated during the counseling session, the staff should routinely provide written materials outlining at-home and follow-up responsibilities.

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After reading this section, you should be able to answer the following question:
What are the requirements of on-call services?

Provision of On-Call and Emergency Services
While triage can be handled by a variety of staff members, a clinician must be available 24 hours a day, 7 days a week, to answer urgent questions and determine the need for further evaluation. Practices must also have an established plan for 24-hour surgical and emergency backup services, either on-site or via collaborative agreements. Depending on facility staffing, on-call triage duties can rotate among qualified staff members, including counselors, administrators, and clinicians.

Medical abortion services do not necessarily involve more calls to the provider than do surgical abortion services. In one study, about two thirds of providers reported receiving either fewer calls from medical abortion patients than from women undergoing surgical abortion or the same number of calls.⁸ In a study of ten practices offering medical abortion services, most practices reported receiving very few emergency and non-emergency phone calls from patients in between visits.¹⁰For the most part, experienced providers of medical abortion who have tailored their counseling and information sharing to address common questions and concerns up front do not report significantly more calls from women undergoing medical abortion compared to women who have had a vacuum aspiration.

As a general guiding principle, patients who are adequately prepared regarding what to expect are less likely to make calls for reassurance or clarification during the medical abortion than are those who are not as well prepared.

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After reading this section, you should be able to answer the following question:
What are the treatment options available in case of an incomplete abortion?

Follow-up
For those patients who administer misoprostol at home or do not expel the pregnancy in the office, a follow-up assessment within about 1-2 weeks of the initiation of treatment is necessary to determine if the abortion is complete. In one study, shorter intervals between initial and follow-up visits (i.e., 7 days or less) resulted in more patients returning for that appointment.¹⁰ Note: Some providers treating patients who travel from long distances or otherwise have difficulty returning for a follow-up visit in person may follow up initially through phone contact and using results of serial β-hCG testing by a facility closer to the patient. In these instances a β-hCG is necessary at the initial visit for comparison.

While continuity of care is optimal, any qualified practitioner can provide follow-up visits. In the vast majority of cases, the abortion will be complete, in which case the visit will include a discussion of the experience and post-abortion contraceptive counseling.

For cases of incomplete abortion (pregnancy terminated but not yet expelled), options include continued observation, a repeat dose of misoprostol, or vacuum aspiration. Women with continuing viable pregnancies (diagnosed by persistent gestational cardiac activity on ultrasound at the 2-week follow-up) must be scheduled or referred for vacuum aspiration. Of note, this is not an emergency situation, and the completion can be scheduled at a time that is convenient for the patient and provider.

Since a follow-up assessment to confirm completion of the abortion is critical, practices must establish a standard protocol for tracking patients for whom the follow-up assessment is not completed and for documenting attempts made to contact those patients.

For the rare patient who remains in the office for observation after misoprostol administration, and expels the tissue during that time, confirmation of complete abortion may be possible at that visit.

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Proceed to Administrative and Regulatory Issues.

References for this module