The impact of patient experience on practice: the acceptability of emergency contraceptive pills in inner-city clinics.

OBJECTIVES: This article reports on a study of 119 women who sought and used emergency contraceptive pills (ECPs) at Planned Parenthood of New York City (PPNYC) clinics between June 1996 and May 1997. It focuses on their satisfaction with the method, their attitudes toward ECPs, their reactions to the service, and the impact their perceptions had on changing the provision of care. METHOD: The PPNYC clinical protocol employed the Yuzpe method and fairly conservative procedures, including restrictive screening, a pelvic examination for all new patients, and limited appointment slots. A two-part survey captured information on patient experience with ECPs. RESULTS: The largest group of respondents (40%) found out about ECPs from friends. Almost 90% of the women were using contraception before their visit to the clinic. Sixty-eight percent reported that they sought ECPs because the condom failed. In the follow-up, a majority (57%) reported that they intended to change or had changed their method of contraception--more than three-quarters to a hormonal contraceptive. While generally satisfied with the service, many respondents were cautious of more extensive distribution of ECPs. CONCLUSION: The survey results had a profound impact on services: PPNYC revised the ECP protocol, developed a staff training package, expanded its service, and planned a multidimensional public media campaign. Further research, including a closer examination of participants' cautious attitude toward unrestricted distribution of ECPs, will be needed as PPNYC expands access to ECP.

Abortion education for residents.

Planned Parenthood of New York City established a physician education program in first-trimester abortion using local anesthesia at its three clinics. This paper describes the program's technical and counseling skills curricula, individualized instruction, quality-assurance procedures, obstacles encountered, and solutions implemented. Major obstacles were slow initial recruitment, disincentives of off-site education, and scheduling difficulties. Solutions included grand rounds presentations at local hospitals to recruit residents, considerable flexibility in rotational scheduling, and expansion of instructional staff to include academic physicians as teachers. Since its inception in July 1993, 53 residents and attending physicians have been taught to perform induced abortions at Planned Parenthood, and 25 who completed the program are currently providing abortions around the nation. Planned Parenthood's experience in teaching residents from local hospitals to perform first-trimester abortion using local anesthesia may be valuable for those who wish to implement similar collaborative off-site educational programs.

Knowledge and perceptions of medical abortion among potential users.

Nearly two-thirds of 73 women aged 18-34 who participated in focus groups on medical abortion conducted in three cities had heard about this new abortion method, but only a few could describe it accurately. Once the method was described to them, they cited its potential advantages over vacuum aspiration as being fewer major complications, the absence of surgery, a greater "naturalness," and its use earlier in pregnancy. Women listed as disadvantages the multiple visits needed for medical abortion, the unknown aspects of the new technology, especially regarding the expulsion of the conceptus, and concern that mifepristone would make an abortion too easy and lead some women to take the decision lightly. More than one-third of discussants said they would choose mifepristone if the method were available.

PIP: The aim of the study was to assess the level of knowledge about mifepristone (RU-486) among US women and to examine the perceived advantages and disadvantages of the drug compared with surgical abortion. In May 1994, 8 focus groups were conducted on medical abortion with 73 sexually active women ages 18-34 recruited from family planning clinics: 3 groups were held with 30 non-Hispanic Whites, 3 with 27 Blacks, and 2 with 16 Hispanics in New York City, Los Angeles, and Portland, Oregon. The mean number of years of education was 13.4 years. 78% were single, 63% had ever been pregnant, and 45% had had an abortion. 63% of 73 women had heard about this new abortion method, but only a few could describe it accurately. Some asserted that RU-486 was the morning-after pill, others referred to it as the abortion pill which was not available in the US. Once the method was described to them in a written profile, they cited its potential advantages over vacuum aspiration as fewer major complications, no risk of uterine perforation, the absence of surgery and anesthesia, its natural and noninvasive nature, and its use earlier in pregnancy. Women listed as disadvantages the multiple visits needed for medical abortion, the unknown aspects of the new technology, especially regarding the expulsion of the conceptus, and concern that mifepristone would make an abortion too easy and lead some women to take the decision lightly. Most women perceived the 2-day wait between pills as disadvantage, and they were curious about the effect on the fetus, if any, if subsequently the pregnancy were carried to term. More than 3/4 of the 27 women who selected RU-486 said they preferred it because it avoids surgery and anesthesia. 1/3 of these cited the absence of the risk of uterine perforation and infection.

Listening and learning from women about mifepristone: implications for counseling and health education.

The careful, reflective, and honest way in which the women in the study analyzed, questioned, and explored the benefits and disadvantages of a mifepristone abortion compared with vacuum aspiration yielded an extensive list of information needed by women to make informed choices as well as an understanding of the diverse social contexts in which choices are made. Needed information identified by this study included technical information about the drugs themselves and their mechanisms of action, roles and responsibilities of health personnel, and descriptions of other women's experiences with mifepristone. A multiplicity of factors entered the decision-making process, demonstrating at the same time a complexity and flexibility of thought. In their hypothetical evaluation of mifepristone, women weighed such factors as experience with childbirth, spontaneous abortion and vacuum aspiration, specific issues for teenagers, lack of a support system, experience with herbal emenagogues and nonprescription drugs intended as abortifacients, and the relative dependence on health care providers. Social, personal, and cultural factors entered into women's interpretation of the different options. These socio-cultural contexts can profoundly influence decisions and potentially affect clinical outcomes. If health care professionals are not proactive, do not fully provide answers to questions (even if unasked), and fail to probe for specific life circumstances, then poor choices and poor outcomes may follow with long term negative consequences for clients.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: Focus group discussions proved to be an effective modality for identifying potential barriers to mifepristone/misoprostol-induced abortion as well as special informational and counseling needs. The eight focus groups, conducted in 1994 in New York, Oregon, and California, included a total of 73 nonpregnant White, Black, and Hispanic women recruited from local family planning clinics. The mean age of respondents was 25.8 years; 63% had been pregnant and 45% reported a prior abortion. Respondents were asked to identify the information they would need to make an informed choice between vacuum aspiration and mifepristone/misoprostol abortion. Their questions centered around the drugs and their mechanisms of action, the abortion process (especially pain and the appearance of the expelled products of conception), postabortion fertility, and the role of health care staff. Discussions identified several factors--e.g., the length of time a woman requires to make a decision to abort, the degree of control she wants to exert over the abortion process, religious beliefs, and support from significant others--that can help counselors to identify women for whom vacuum aspiration may be a more feasible alternative. Overall, the group discussions highlighted the importance of a woman's unique life circumstances to reproductive health decisions.

RU 486 beyond the controversy: implications for health care practice.

RU 486 has been mired in controversy since it was first synthesized in the 1980s. This paper assumes that RU 486 will eventually be available in the United States and examines how clinicians might integrate it into practice without compromising quality of care and patient safety. The mechanisms of action of RU 486, its prostaglandin augmentors, and other first-trimester abortifacients are briefly reviewed. Significant and often misunderstood issues are discussed, including the concern that women will fail to return for the second visit, in which they receive the prostaglandin; the need for back-up facilities; women's acceptance of RU 486 as an abortifacient; and its potential to increase abortion services to the underserved. The paper argues that RU 486 has implications for positive changes in the interpersonal dimensions of health care and discusses the adaptation in the organization of care that will have to take place in order to make RU 486 available to all women who might choose to use it.

Observations on abortion in Zambia.

This report describes the findings of a preliminary investigation of women who sought treatment for abortion from the Gynecological Emergency Ward at the University Teaching Hospital (UTH) in Lusaka, Zambia. Barriers to obtaining legal abortions are identified and the harsh experiences of women seeking treatment for complications of illegally induced abortion are discussed. The data contribute to an understanding of the intensity of abortion for Zambian women and draw attention to the value of small-scale, qualitative research on women's reproductive health care needs. It is suggested that a study be planned at UTH to determine how health care delivery can be improved for women who seek abortion.

PIP: This report describes qualitative observations of the 1 day at the Gynecological Emergency Ward, University Teaching Hospital, Lusaka, for September, 1988; and 2 case histories of abortion patients. These women had complications of illegally induced incomplete abortions. They came to the (UTH) for medical treatment. Each day 3 out of 10 illegally induced abortion patients complete the abortions on a concrete floor with no medical care. No medication or analgesics can be given without a prescription by a physician. If it is determined that a woman has had a proper, complete abortion, she is observed for at least 8 hours and released. Only 1 physician is available to many women. Due to blood shortages, few women who need blood get it. Women who have abortion- related infections need antibiotics which they may or may not get. Hysterectomy, ectopic pregnancy, and sterility are complications of improperly performed abortions. The consent of 3 physicians is required for an abortion--1 must be a specialist in a branch of medicine related to the woman's reason for wanting an abortion. Physicians are reluctant to schedule appointments despite the legalization of abortion in 1972. Junior physicians perform the abortions in the operating room. Some private physicians insert an IUD to induce abortion and tell the women to go to the gynecology ward at the hospital when bleeding begins. Other private doctors insert a plastic cannula and tell the women to go to the hospital ward. Most women go to traditional healers or midwives who insert roots soaked in water into the cervix which act as an irritant/dilator. Traditional healers also provide herbs claimed to be abortifacients which are taken in tea or eaten. At least 114 of the women at UTH induce abortion themselves by inserting plants or twigs into the cervix. Desperate and often the youngest women drink gasoline or detergents or take large overdoses of chloroquine, aspirin, or other toxic substances. All the women are afraid of dying from abortions. Poorly performed abortion is a major cause if maternal mortality in the 3rd world. Abortion-related death rates have been guessed to be 50- 100/100,000 illegal procedures compared to 1/100,000 legal abortions in the US. A study should be planned at UTH to determine how health care delivery can be improved for abortion seekers.