mh counselling abortion-pht-august06.final version

8/19/2019 MH Counselling Abortion-PHT-August06.FINAL VERSION

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FINAL VERSION-MENTAL HEALTH COUNSELLING IN ABORTIONPsychosocial Health Technician input - by Zohra Abaakouk

MSF OCBA , August 2006

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MENTAL HEALTH COMPONENT INABORTION COUNSELING

INTRODUCTION

Facing to the main medical consequences of unsafe abortion and the recurrent demand ofabortion practice by of the beneficiaries of our projects, the International Council of MSFdecided to adopt the following resolution: “The availability of safe abortion should beintegrated as a part of reproductive health care in all contexts where it is relevant ”.

Putting in practice the MSF IC resolution with reference to abortion, MSF OCBA drew up a

policy paper recommending that: “ patients will receive private counseling and informationabout the procedure, its medical consequences including potential complications, and theexistent networking in the context. The counseling will present a choice of safe andappropriate methods and will be given a few days before performing the medicalintervention, in case she would change her mind ”.

MENTAL HEALTH CONSEQUENCES OF THE ABORTION

An unwanted pregnancy is a life event that can be considered stressful; feelings of self-confidence are strongly compromised and affect personal abilities to cope with the

experience.

When a women seeks an abortion she is engaging in a stress management process andnot simply on a matter of self convenience. Abortion can be viewed as a threat, a copingtool or both. The role of this appraisal of the woman is crucial to provide adequate mentalhealth support.

Abortion involves a process of making a thoughtful decision, full of painful self-judgments,and whatever alternative is chosen, it requires the courage to strip expectations fromoneself and to take responsibility for irrevocable actions.

Counselling is more than providing information. The focus of this counselling is helping thewoman to reflect about her obstacles and her possibilities. It is important to bear in mindthat the decision is more important than information given

1.

DECISION OF PROVIDING ABORTION COUNSELING

The decision of who could provide counselling related to abortion services will depend onthe mission itself.The pre-counselling abortion will be provided when a woman solicits MSF teammembers for having further information regarding abortion and/or for asking anabortion practice.

1 WHO: Post abortion family planning


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MENTAL HEALTH AND LEGAL GROUNDS

WHO also agrees that in many countries mental health grounds are included in the law tofacilitate the access to abortion services for women survivors of rape and/or incest.

2

WHO mention this problem, explaining that in many countries the interest is to preservewomen’s health and therefore understanding health as psychical, psychological and socialwell being, mental health has been included.

MSF-OCBA will contemplate the legal grounds of each mission, case per case, beforeproviding the abortion act to women who asked for and/or need. MSF will request aconsent form signed by the patient.

ROLE & USEFULNESS OF THE DOCUMENT

The forms we present as follows, attempt to be practical and applicable in the field. Theforms present general guidance for ensuring the provision of high quality mental healthsupport related to abortion services. The forms should be used by teams as a guide toimplement mental health component related to abortion counseling.

As such, we consider your feedback to be fundamental to confirm its usefulness and tocontribute practicalities fitting to each context.

For more information regarding mental health issue in abortion, contact:

[email protected]

2 WHO: aborto sin riesgos; guía técnica y políticas para sistemas de salud, Ginebra 2003


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TIP 01 BASIC RESOURCES FOR AN ABORTION

SERVICE OF QUALITYFollowing the principles of the International Planned Parenthood Federation

3, every

woman has right to: Information – to learn about her reproductive health, contraception and abortion

options. Access – to obtain services regardless of religion, colour, marital or economic

status, or age. Choice – to decide freely whether to use contraception or have an abortion, and

among methods.

Privacy – to have a private environment for counselling and services Confidentiality – to be assured that any personal information will remainconfidential.

Dignity – to be treated with courtesy, consideration and attentiveness. Comfort – to try to make her more comfortable when receiving services Continuity – to receive follow-up care and contraceptive services and supplies for

as long as needed

Opinion – to express her views on the services offered (1) “A guide to providing abortion care” p.39, IPAS, 2001.

Counselling for abortion requires that the situation of the woman is discussed calmly untilshe is ready to make what must be HER OWN DECISION. (2)

♦ What is counselling? (3)

Counselling is a structured interaction in which a person voluntarily receives emotionalsupport and guidance from a trained person in an environment that is conductive to openlysharing thoughts, feelings and perceptions.

♦ What is the purpose of abortion counselling ? (4)

The purpose is to help the woman to take her own decision4

.

♦ The role of the counsellor is to: (3)

- Request and affirm the woman’s feelings- Help the woman clarify her thoughts and decisions about her pregnancy, her need forabortion treatment, the treatment plan, her future sexual and reproductive health

3 IPPF4 Which could be:

a) abortion,b) continuing the pregnancy and parenting,c) continuing the pregnancy and setting up an adoption plan.


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- Help the woman explore her feelings and decisions about her interpersonal relationshipsand life circumstances related to her sexual and reproductive health- Ensure that the woman receives appropriate answers to her questions about her healthcondition, test results, treatment and pain-management options and follow-up care- Address any other concerns that the woman has at that time

- Refer the woman to additional services when necessary.

♦ Counselor’s skill (3)

- Remain open, empathic and non judgmental- Extend compassion and respect to every patient, regardless of the patient’s reproductivebehaviours and decisions- Separate our own values and attitudes from those of the patients- Respect patients independent values and attitudes- Honour every patient’s feeling, perceptions and decisions

♦ Keys to perform appropriate pre & post-abortion counselling:

- Consideration of the patient’s physical and emotional state is essential- Making her feel comfortable to ask questions and discuss concerns- It should be conducted in a private location. If she is hospitalised due to a medicalcondition and cannot move to a private room, a curtain should be use at list to providevisual privacy.

Information and counselingThe provision of information is an essential part of quality abortion services. The

information must be delivered in a caring way, easy to understand and always respectingprivacy and confidentiality.

Decision-making counselingIt is essential to help the woman consider her options and ensure that she can make adecision free of pressure. Counselling should be voluntary and confidential. All informationand time should be give to the woman to assure a free and informed choice, even if thatmeans to consider that she returns to the clinic later


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TIP 02PROVIDE A PRE-ABORTION COUNSELING OF

QUALITY

Why ? ---------------------------------------------------------------------------------------------▪ Provide information▪ Address the woman’s emotions▪ Support woman’s decisions (1)

Who can provide the pre-counseling ? -----------------------------------------------▪ Public health structure (MoH)▪ Private health structure▪ NGOs identified which are able to provide this kind of service

▪ MSF5

: medical doctor (expatriate), midwife (expatriate) and/or national staff member.This will depend on MSF decision taken for each specific country.

Who can receive the pre-counseling ? -----------------------------------------------Every woman who solicit MSF teams for an abortion practice and/or for further information.

How to provide the pre-abortion counseling ? -------------------------------------▪ Main rules: (1)→ maintain physical and acoustic privacy during all counseling→ encourage the woman to ask questions or express concerns

→ respond patiently using words that she can understand→ should be done with respect for the woman’s needs and without expressing judgment of

the woman, either verbally or non-verbally→ everything should be treated confidentially

▪ Information provided The minimum information that a woman must be given can be summarised in the followingpoints:- what will be done during and after the procedure- what she is likely to experience (e.g. menstrual-like cramps, pain and bleeding)- how long the procedure will take

- what pain management can be available to her- Risks and complications associated with the method- when she will be able to resume her normal activities, including sexual intercourse- follow up care

▪ Interviewing skill (3) & (4) → effective communication: focusing on patient’s needs, using active listening skills,

including both verbal and nonverbal communication, showing patients that they arecompletely attentive and responsive to their needs.

→ active listening: using multiples senses to gather relevant information, conveyunderstanding and encouraging the patient to talk about her feelings andcircumstances.

5 It could be one or two MSF professional


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→ verbal communication: using open-ended and/or closed-ended question. see annex 02.1→ non-verbal communication: observing the person’s facial expressions and bodylanguage (person’s physical position, posture and gestures communicate feelings) see annex 02.2

→ closing a counseling session:

- providing a short summary of the key concepts discussed,- asking the woman what additional questions she has and answer them, - asking the woman to repeat back any verbal instructions or suggestions, - making sure the woman has written instructions or referrals, - explaining what to expect during the remainder of the clinic visit or in follow-

up care

▪ She may not be ready to make a decision during this appointment (1)▪ If she chooses (1)→ determine which methods are medically appropriate→ give her information on all available methods for which she is eligible → help her choose the one that best suits her needs, wishes and circumstances→ explain possible complications→ describe what will happen during the procedure, including what she can expect to feel → follow all informed-consent protocols to ensure that she understands what is going to

happen and if she still wants to have the abortion

▪ If she doesn’t choose (1)If the patient does not wish to have an abortion, or she is uncertain, discuss otheroptions with her. If she chooses not to have an abortion, refer her to prenatal care

Bear in mind ! (1) ------------------------------------------------------------------ → Remember that many women are accustomed to relying on health workers expertadvice when making health decisions. Help her clarify and express her own preferencesby asking questions→ Ask the patient if she has someone with her and would like that person to be presentduring the counseling and/or procedure, if clinical protocols allow it→ Do as much of the counseling and take as much of the patient’s medical history aspossible before she undresses for the clinical assessment→ Remember that many women encounter domestic violence. Some women seekingabortion care are pregnant because of rape or incest, and some may face violent angerfrom their family or partner for being pregnant or having an abortion. Be sensitive to this in

counseling and provide women with referrals to further counseling as appropriate

Bibliography -----------------------------------------------------------------------(1) “A guide to providing abortion care” p.38-40, IPAS, 2001.

(2) “Psychology and reproductive choice Forum: Abortion, informed consent and mental health,

Nancy Felipe Russo & Lisa Rubin (3) “Woman-Centered Post abortion Care : Reference manual”, Herrick, Jeanine, Katherine Turner, Teresa

Mclnerney and Laura Castleman, 2004.

(4) Information and training guide for medical-abortion counseling. IPAS, 2003

Annex --------------------------------------------------------------------------------

Annex 02.1: Verbal communication: open-ended questions and reflecting feelingsAnnex 02.2: Non-verbal communication


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TIP 03PROVIDE A POST- ABORTION COUNSELING OF

QUALITY

Why ? -------------------------------------------------------------------------------▪ Help the woman to acknowledge feelings and feel supported about them the woman canmove ahead in the process, learning and using important coping skills.

Who can provide the post-abortion counseling ? --------------------▪ The same professional(s) who did the pre-counseling and the practice(see tip 02 – “who can provide the pre-abortion counseling ?”)

Who can receive the post-abortion counseling ? ---------------------The ones who had previously a pre-abortion counseling and an abortion.(see tip 02 – “Who can receive the pre-abortion counseling ?”

How to provide the post-counseling ? -----------------------------------▪ Main rules: (1)(see tip 02 – “How to provide the pre-abortion counseling ?”) ▪ Information provided (1)→ start by informing the woman that she can become pregnant again almost immediately

after an abortion

→ contraceptive methods can be started immediately after a safe, uncomplicated abortion6

→ talk about emergency contraception, including how to use it and where to get it → ask the woman about her future reproductive plans in a manner appropriate for her age▪ If she wants to delay further pregnancies for a period of time (1)→ make sure she is familiar with the methods available→ ask if she has used contraceptive methods previously and how those methods worked

for her→ make sure she knows how to use any contraceptive method she accepts or has an

appointment to obtain her chosen method before she leaves your care.▪ If she cannot receive her chosen method immediately→ make sure she leaves with a temporary one

▪ To conduct post abortion counselling one must take advantage of the medical check ups.The revision of the emotional state of the woman and to attempt to normalise the differentreactions she may be experiencing.

▪ Keys to perform appropriate post-abortion counselling:

• consideration of the patient's physical and emotional state• Provision of information on family planning methods, taking into account the

woman's current clinical and personal situation, and her individual preferences. This

6 It is best to provide this information before the procedure


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information should include how to use the method, its effectiveness, risks andbenefits and management of side effects

• Check emotional state at each medical consultation post-intervention • Normalize the emotional reactions • To refer the patient to psychological consultation if the grieving process still difficult

after 4-6 weeks


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BIBLIOGRAPHY

(1) “A guide to providing abortion care” p.38-40, IPAS, 2001.

http://www.ipas.org/publications/en/IMPEL_E02_en.pdf

(2) “Abortion, informed consent and mental health”, Nancy Felipe Russo & LisaRubinhttp://www.prochoiceforum.org.uk/psy_coun11.asp

(3) “Woman-Centered Post abortion Care : Reference manual”, Herrick, Jeanine,Katherine Turner, Teresa Mclnerney and Laura Castleman, 2004.Xxxxxxxxxxxxxxxxx

(4) Information and training guide for medical-abortion counseling. IPAS, 2003

http://www.ipas.org/publications/en/Medical_Abortion/INFMEDAB_E03_en.pdf

FURTHER READINGS

• Final minutes MSF International Council meeting. Geneva 19-21 November,2004

• Policy paper. Safe abortion in MSF-OCBA. DRAFT VERSION, October 2005

• Pre-post abortion counseling, Benson hospital . MSF Spain, May-July 2006

• Mental health risks of abortion – Scientific studies reveal significant riskmajor psychological sequelae of abortion. Westside pregnancy resource center.http://www.wprc.org/21.46.0.0.1.0.phtml

• Safe abortion: technical and policy guidance for health systems. World HealthOrganization, Geneva 2003http://www.who.int/reproductive-health/unsafe_abortion/index.html

• Safe abortion: technical and policy guidance for health systems. World HealthOrganization, Geneva, 2003http://www.who.int/reproductive-health/publications/safe_abortion/safe_abortion.pdf

• Mental health consequences of abortion and refused abortion. Watter WW,Canadian Journal of Psychiatry, 1980http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Watter+WW%22%5BAuthor%5D


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Annex 02.1 Verbal communication: open-ended questions and

reflecting feelings

The way people ask questions can either encourage or discourage others from engagingin conversation with them. Open-ended questions begin with “how,” “what,” “when” and“tell me about.” They cannot be answered with just “yes” or “no.” By asking questions thatrequire more complete answers, a counsellor is encouraging the patient to offer moreinformation and engage fully in the conversation. Closed-ended questions may begin with“do,” “will” or “are” and are answered with “yes” or “no.” When the counsellor asks aclosed-ended question and the patient responds with “yes” or “no,” the counsellor must

askanother question to continue the conversation.Counselors should avoid asking open-ended questions beginning with “why,” since thisform of questioning is often perceived as being judgmental.For example, a counsellor might ask a woman, “Why do you feel relieved about havinghad a miscarriage?” The implied judgment is that a woman who has a miscarriage shouldnot feel relieved.The counsellor can follow up the patient’s response to an open-ended question with astatement that reflects her understanding of the woman’s feelings and concerns. If thecounsellor is unsure whether she has understood the patient correctly, she can add aquestion at the end of the statement, such as “Is that correct?” This will give the patient the

opportunity to confirm or correct the counsellor’s understanding. In order to ensure that allof the patient’s concerns are addressed, it may be helpful to ask her what other questionsshe has or what else she would like to discuss.

► Open-Ended Questions and Possible Responses

Question: “What brings you here today?” Answer: “I came here because I had a miscarriage.”Question: “How do you feel about your miscarriage?” Answer: “I feel relieved.”Question: “Tell me more about this. What makes you feel relieved?" Answer: “I didn’t want to be pregnant in the first place. I just had my third child a year ago.”

► Closed-Ended Questions and Possible Responses

Question: “Did you have a miscarriage today?” Answer: “Yes.”Question: “Do you feel sad about it?” Answer: “No.”Question: “Are you happy about it?”

Answer: “No.”


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Annex 02.2 Non-verbal communication

People communicate many of their thoughts and feelings without speaking a single word. A perceptive person can often tell how someone else is feeling before they exchange anywords by observing the person’s facial expressions and body language. Body languagerefers to how a person’s physical position, posture and gestures communicate feelings. Bypaying close attention to people’s verbal and nonverbal communication, a counsellor canmore fully understand a patient’s feelings.

Counsellors should remain observant about differences between a patient’s verbal andnonverbal cues, since some people may have difficulty expressing their feelings verbally. After observing nonverbal communication, counsellors should verbally confirm their

interpretation of the expressions with patients to prevent any miscommunication.For example, if a woman says she feels fine but has a sad facial expression, thecounsellor may want to communicate this and ask for the patient’s response: “You say youfeel fine, but you look sad — can you tell me more about that?”

A trusting patient-counsellor relationship is based not only on the words they exchange butwhat they see and sense about each other. A counsellor can use nonverbalcommunication to show concern for a patient by facing her, removing any physical barriersbetween them such as a desk or counter, leaning slightly forward, making appropriate eyecontact, nodding and using a reassuring tone.

Counsellors who practice effective communication:

Stay attentive and focused on the patient and her needs.Use nonverbal cues to convey interest in and concern for the patient.

Ask open-ended questions and use encouraging words to help the patient talkopenly.Pay close attention to the woman's spoken words.Listen for the meaning underlying her words.Observe the patient's nonverbal expressions.Listen carefully to the woman’s responses.Follow up with appropriate questions and feedback to encourage the woman to

explore her feelings further.

Counsellors who do not practice effective communication:

Make assumptions about the patient and her needs.Focus on their own priorities rather than the patient’s need.Indicate their disinterest through nonverbal expression. Ask only closed-ended questions.Do not listen carefully.Interrupt or speak over the patient.May misunderstand the patient’s words.

Do not pay attention to the patient’s nonverbal cues or misinterpret them.Do not check back to make sure that the patient understood them.


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Allow interruptions such as telephone calls or people coming into the counsellingspace.Show distraction by fidgeting, frequently looking away, yawning or doingsomething else while the conversation is taking place.

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