Module 1: Consultation – communication and decision making

3. Communication

In this example of a telehealth consultation, Simon Snook of the Women’s Clinic discusses abortion options with Emma, who is unexpectedly pregnant and living with her partner in a campervan in Central Otago. The 26 minute conversation includes abortion options and safety, Emma’s medical history, estimated gestation and contraception options, and a description of the EMA process.

Tikanga in abortion care

What is Tikanga?

One of the ways we honour and respect our obligations to Te Tiriti o Waitangi and tangata whenua (the indigenous people of the land) is through the appropriate use of tikanga. Tikanga is following specific protocols and procedures with the intent to honour Māori holistic cultural practices. These practices reflect spirituality and indigenous values such as tapu, noa and mana. Māori beliefs, values and concepts are inherited and practiced from generation to generation. Important values are also te reo (the language), whenua (the land) and the concepts of whānau, hapū and iwi (family and extended family group). Integral to tikanga are Māori world views encompassing the atua (gods), creation story and a holistic approach to health spanning the realms of wairua (spirituality), hinengaro (psychological), tinana (physical) and whānau (family).

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The connection to wairua (spirit) is particularly intrinsic to Māori traditional beliefs and in healthcare settings we can maintain and protect a person’s wairua, tinana and hinengaro with specific practices such as karakia (incantations, blessings, prayers). Behaviour and practices not consistent with beliefs, values and concepts can distress Māori and cause lack of confidence and hence participation in health care services.

In later modules we describe specific ways in which practicing tikanga with the intent to honour a pregnant person’s beliefs may enhance abortion care for both Māori and non Māori.

Practicing tikanga safely can often feel overwhelming for health care professionals. The best way to work through this is asking for help from colleagues, learning more from your local iwi, seeking formal training and learning from the people you see in your health care setting. As in any culture, no two people will believe, value or practice in the same way and there are whanau, iwi, and regional differences to be aware of. Be guided by the person in front of you, acknowledging their sovereignty (tino rangatiratanga) in deciding what path, karakia, supports they would like during their care. When using and offering tikanga in the right way with the right intention it is mana enhancing for you, the pregnant person and their whānau.

The following audiovisual aid discusses how the concepts of tapu (restricted), noa, (free from restriction) and mana are used to guide tikanga.

Family violence

A routine enquiry about intimate partner violence (IPV) should be made to all people attending abortion services, accompanied if necessary, by the provision of appropriate information and support. The 2016 Ministry of Health Family Violence Assessment and Intervention Guideline is a practical tool to help health providers make safe and effective interventions to assist victims of interpersonal violence and abuse.

IPV is common among women and those in the LGBTQIA+ community. One in three Aotearoa New Zealand women have experienced physical or sexual violence by a male intimate partner in their lifetime. In one study of 62 women attending an abortion clinic in Aotearoa New Zealand, the self-reported lifetime prevalence of physical or sexual abuse was 50%. It is important for those working in reproductive health settings to be aware that sexual assault occurs in the context of relationships. IPV can also include reproductive and sexual coercion.

Reproductive coercion includes behaviours that interfere with contraception use or pregnancy, such as threatening to end a relationship if the person does not get pregnant, or if they do not terminate a pregnancy. Sexual coercion includes behaviours of pressuring or manipulating a person into unwanted sexual activity through non-physical means. Past or current IPV in a person’s life can have profound implications for physical, sexual and reproductive and psychological health. Healthcare providers need to have the skills to identify IPV, and provide appropriate support, referrals and follow-up care as required.

Questions you may consider asking include:

• Does your partner support your decision about when or if you want to become pregnant?
• Has your partner ever forced you to do something sexually that you didn't want to do or refused your request to use condoms?
• Has your partner ever tried to get you pregnant when you didn't want to be pregnant?
• Are you worried your partner will hurt you if choose not to do what they want with the pregnancy?

The World Health Organization (WHO) recommends five minimum requirements which need to be in place prior to the implementation of routine inquiry for IPV:

• A protocol on standard IPV response procedure
• Staff training on how to ask, and appropriate minimum response guidelines
• A private setting
• Assurance of confidentiality of response
• A system for referral to appropriate support services

New Zealand is taking a leading role in terms of recognising and implementing a national system change approach for supporting health care providers’ response to victims of IPV and child abuse. Contact your Ministry of Health’s Violence Intervention Program (VIP) Coordinator to obtain more information about the program.

IVP Referral pathways:

• If there is an imminent threat to patient, staff or others: call on-site security or 111
• If an alleged assault or abuse needs urgent intervention, contact:
  • Police
  • Oranga Tamariki
• Ensure the person has a safe place to go. Consider:
  • Hospital admission
  • Emergency shelter e.g. Women’s Refuge
  • Family or friends
• Consider the need for an acute adult mental health assessment
• Arrange an appropriate follow-up consultation or phone call
• Other resources:
  • It’s Not OK website and Family Violence Information Line: 0800 456 450 (available 24 hours a day, 7 days a week)
  • Shine website and helpline 0508 744 633 (available 24 hours a day, 7 days a week)
  • Safe to talk – Kōrero mai ka ora website and Sexual Harm Helpline: 0800 044 334 or text 4334 (available 24 hours a day, 7 days a week)

Rangatahi / Young people

Rangitahi / young people who are seeking abortion care need to be provided with youth friendly care. There are a number of courses on youth friendly care available, including the Working with Youth: HEEADSSS (Home, Education, Employment, Eating, Activities, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety) wellbeing framework developed by The Goodfellow Unit. We recommend their comprehensive 4 hour course. There is also a 35 minute audio summary describing how to complete an assessment in a short period of time.

Abortion care for youth has similar outcomes to those for other people seeking abortion. However, there are issues that are important to consider for youth seeking abortion care including safety at home and sexual coercion. It is important that abortion services have policies on how to manage care and protection concerns.

Rangitahi / youth may have strong concerns about confidentiality. It is important to reassure the person that abortion care is confidential, and that information does not need to be shared with whanau or other health care providers if they do not want it to be. However there are instances where confidentiality must be broken, for example, if they or someone else is at risk, and they must be made aware of this.

Cultural safety

Cultural safety emphasises self-reflection upon one’s own cultural mores and the likely effect of how bias and prejudice arising from that cultural perspective might affect professional behaviour and equitable health outcomes. In the 1990s, Irihapeti Ramsden and other Māori nurses developed the key definitions and strived for social justice using the model of health practitioners as ‘border workers’, working at the interface between the system, the patients and the whānau. An important proficiency in providing culturally safe abortion care is that “safety” is determined by patients, whānau and communities. Culturally practitioners make the time and space for open, authentic conversations and listen to and action feedback and recommendations.

The cultural safety training plan released in February 2023 by The College of Medical Councils (CMC) in partnership with Te ORA Māori Medical Practitioners Association provides the latest components that contribute to optimal health for Māori. It is a superb, comprehensive resource for individuals and organisations to grow their knowledge base to support the evolution of health care practitioner training towards cultural safety. Their approach incorporates three components in a framework to ensure all elements of “culture” are considered.

• Hauora Māori - historical and contemporary Māori health knowledge
• Cultural competency - knowledge and skills to work effectively within cross cultural contexts
• Cultural Safety - developing critical consciousness using self-reflection on internal biases

Providing culturally safe abortion care in Aotearoa New Zealand includes a broader approach to include the diverse population: the 2018 census data shows that our population includes members of over 160 ethnic groups. The Ministry for Ethnic Communities, established in 2021, represents the 20 per cent of New Zealanders who identify as belonging to African, Asian, Continental European, Latin American or Middle Eastern ethnicities. Their website resources include the Ethnic Communities’ Data Dashboard, an interactive tool to explore national and regional data on ethnic communities from the 2018 census; and an introductory Intercultural Capability online learning programme.

Just over eight per cent of the population belong to ethnicities which fall within Stats NZ’s ‘Pacific Peoples’ grouping, with two thirds of these people born in Aotearoa New Zealand. The largest Pacific community, making up almost half of the Pacific Peoples group, is Samoan, followed by those identifying as Tongan (just over one quarter of the group).

Further reading and resources for cultural competency continuing education:

• The New Zealand Medical Council statement on cultural safety
• “What is cultural competence?” on the Health Navigator website
• Le Va’s Engaging Pasifika cultural competency training programme
• The Populations section of the Ministry of Health website
• Learning and education modules on understanding bias in health care from the Health Quality & Safety Commission New Zealand (HQSC)
• eCALD® online courses for health practitioners to gain cultural understanding and develop skills to work with migrant and refugee patients from Asian, Middle Eastern, Latin American or African backgrounds.
• The Languages section of the Health Navigator website
• Connecting Now (0800 854 737) a professional telephone interpreting service who help government agencies to communicate with clients with limited English through telephone/video interpreters available 24 hours a day, seven days a week, in over 180 languages

Abortion services and disabled people

As part of the process of developing this training content, The New Zealand College of Sexual and Reproductive Health (NZCSRH) sought feedback from people that identified as having disabilities, about their experiences accessing sexual and reproductive healthcare in Aotearoa New Zealand. A report was produced from the findings of an online survey distributed through social media and community contacts, a follow-up hui that took place over zoom and one on one interviews. The major conclusions from this work with regard to abortion training are summarised below, and the full report is available here.

The survey had good engagement, with 63 participants taking part. In Aotearoa, disabled people make up 24% of the population as reported by the 2013 Disability Survey, the most recent data currently available. Participants mostly came from the main centres of Dunedin, Wellington, and Auckland.

The major overarching theme from the responses is that disabled people are having some negative experiences when accessing sexual and reproductive healthcare in Aotearoa. The survey found that participants were having difficulties feeling heard (or were completely unable to be heard) by practitioners during appointments (46% of participants) and being able to speak for themselves at those appointments (24% of participants). It is essential that clinicians listen and learn from people about their specific requirements to access services, and consider the added needs of chronically ill disabled people or those with complex medical needs when providing their abortion care.

Participants reported in interviews following the survey that there are additional things to take into consideration when making choices with their healthcare. They all spoke of preferring to use their general practitioner over more “transactional” forms of sexual healthcare such as through family planning or hospital sexual health clinics.

“I prefer to go to my GP as she knows my entire history and if it ends up turning into a complex thing, then she is already involved”

The reasons given for choosing their GP over other care services overlap with the issues that over 85% of our survey participants rated as very important or essential in their appointments with sexual and reproductive healthcare practitioners:

• Reliable and safe treatment
• High clinical quality and knowledgeable staff
• Confidentiality
• Non-judgemental services
• Sympathetic and kind staff
• Having control over the process, the ability to stop at any stage and take time if needed
• Good advice and information
• Choice in abortion procedures, medical and surgical options, and pain relief options
• Ease of access to clinic/services
• Opportunity for counselling if required
• Fast access to treatment
• Provision of more effective contraception services as part of an abortion service
• STI Screen and treatment available as part of abortion care

In comparison, the thing that was labelled of least importance was:

• Little wait time in the clinic (13% of participants rated it “not important” and 40% of participants rated it “Quite important”)

“For me personally, I would be prepared to wait all day for one doctor/nurse that is kind, compassionate, listens and is knowledgeable. My chronic illnesses are complex so I need a professional who is prepared for listening”

Several of the survey participants spoke of lacking a strong therapeutic relationship with their care provider, and they voiced a need for stronger relationships to be developed.

There was additional crossover with LGBTQI+ and Māori issues, highlighting the need for an intersectional approach to care.

“Cultural competency – especially for rangatahi Māori, who might be struggling with the idea of abortion. For me, I didn’t know the spiritual ramifications of abortion in my Māori community (for those unaware, it’s often that the wairua of your pēpi still exists and can become a guardian for you in your life), and I had already started forming a connection to my pēpi when I had my abortion, although I don’t regret my abortion at all, and I think I gave them the right send-off when I did undergo my abortion. But I wish someone had given me some ao Māori guidance regarding abortion. I’ve mostly kept quiet about my experience for seven years because I’m innately worried about how my Māori community will treat me, even though realistically my community would most likely awhi me and my choice. I was also young and relatively alone when I had my abortion and am no longer in contact with the main support person who helped me through it, and I know I now fit into some racially negative stereotypes which could possibly be used against me, so it has made retelling my story quite difficult and isolating.”

In the survey, 22% of the participants marked access to transportation to and from sexual and reproductive healthcare appointments as a significant issue. One participant brought up the use of a medical practice run taxi service that provided transport for people to and from appointments. This is also a model that has been used in the wider medical care sector. An alternative to a taxi service could be providing partial or full funding of taxi services depending on the needs of the person, the area they are travelling from and the access to public transport available. Considerations surrounding privacy relating to this type of service would need to be investigated further.

“For people living in rural communities who can’t get the access even more than me who lives in a city. The transport thing is so important, it’s getting people to those appointments because once you’re there you’re taken care of well. It’s just getting there and back is the issue. If we don’t know where to go first of all that’s a major issue and then on top of that it’s how do you even get there in the first place? Can you find it yourself? Is it safe to go to that sort of place?”

In summary:

• The disabled person needs to play the central role to discussions about their care. There is a saying in disability advocacy “nothing about us, without us”. Disabled people are often experts on their own support requirements, and this should be recognised and respected by healthcare providers.
• abortion service providers should be aware of the need to take an intersectional approach to care with many people, whose multiple identities as, for example, disabled and Māori, or disabled and rainbow people, need to be considered for optimal care.
• Practitioners need to carefully consider how accessible their service is for those with a range of physical and intellectual disabilities.

Further reading and resources:

• The New Zealand Disability Strategy aims to provide guidance on disability issues (2016 - 2026) for government agencies, other organisations and individuals
• Whaikaha – Ministry of Disabled People website
• The Office for Disability Issues website
• Disabled Persons Assembly NZ website
• People First New Zealand – Ngā Tāngata Tuatahi website
• New Zealand Sign Language interpreter service available here

Abortion services and rainbow people

Abortion services must provide care for all pregnant people, including trans, intersex, non-binary, and gender nonconforming people. It is important to affirm personal identity and that of the person’s partner (or partners if they are in a polyamorous relationship) and use the person’s preferred pronouns (such as he/him, she/her, they/them) and their name. If you are not sure how someone wishes to be addressed, politely ask. Careful consideration of language use, and the use of non-gendered terms, will help in providing a more inclusive environment for rainbow people.

The Aotearoa New Zealand Trans and Non-Binary Health Survey, Counting Ourselves, is an anonymous health survey designed by and for trans and non-binary people, with the 2022 survey currently underway. Analysis of the 2018 survey responses found that transgender participants were more likely to report negative primary healthcare experiences, and barriers accessing care, when compared to the general population. In comments in the survey, many participants noted they had experienced gaps in knowledge and confidence on the part of healthcare practitioners when providing gender affirming care.

People undergoing testosterone therapy need to use contraception to prevent pregnancy, and if an unintentional pregnancy occurs, testosterone is contraindicated because of potential harm to the foetus from the androgenising effects of treatment. As for all people requiring abortion care, transgender patients need to be informed and involved with all decisions related to their care. A survey of transmasculine people living in Sweden found that pelvic examination could be a particularly problematic and difficult part of their experiences of sexual and reproductive health care. The authors found that better experiences of pelvic exams depended on an empathetic approach by the health care practitioner, involving the person and informing them about the procedure at all stages.

Abortion in transmasculine people who take testosterone may be complicated due to atrophic changes. Dilatation of the cervical canal can be more difficult and consideration should be given to referral to an experienced abortion provider.

We recommend exploring these websites and their resources to learn about providing a welcoming and supportive healthcare service for rainbow people:

• “Supporting Aotearoa’s Rainbow People”: This online resource is designed for mental health professionals, however, it contains comprehensive information and advice for all health professionals based on findings from the Rainbow Mental Health Support Experiences Study and the Out Loud Aotearoa Project.
• Gender Minorities Aotearoa has a freely available online course “Supporting Transgender People” available here. “This course is designed to increase your knowledge of issues affecting transgender people in Aotearoa, and to build your confidence in speaking about these issues and supporting transgender people. It is a 101 course and suitable for people with any level of knowledge on transgender issues.” The course is in three sections and is estimated to take two to three hours to complete. Links for further reading are available in some sections. This website also includes a transgender language glossary which covers many rainbow community terms, while focusing on gender and transgender identities.

Whānau, partner and friend support

People accessing abortion services may choose to be accompanied by whānau members, partners or friends to help them through the process. Joint counselling for the pregnant person and their partner should be available if requested by the pregnant person. It is important to have time alone with the pregnant person to ensure you are complying with their wishes without pressure or coercion.

Where possible during the pre-abortion clinical assessment and procedure itself, healthcare practitioners should aim to include and involve support people as requested by the pregnant person, while ensuring that all decisions are made by the pregnant person.

The DECIDE National Abortion Telehealth Service website has information and advice for people supporting friends and loved ones having an abortion.

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