Module 1: Consultation – communication and decision making

5. Decision making

Overview

This section focuses on decision-making, the final stage of the pre-abortion process, once the pregnancy is confirmed and gestation estimated. Health practitioners need to effectively communicate the pregnancy and abortion options available to the person, providing them with the information they require to make their decisions.

They also need to ensure that the person is aware that counselling is available to them. Abortion related counselling must be in line with the Standard for Abortion Counselling in Aotearoa New Zealand (Ministry of Health, 2022). Health practitioners should have established contacts to refer people for counselling in their local area, or to The National Abortion Telehealth Service (decide.org.nz) counselling service.

Informed consent

All people in Aotearoa New Zealand have the right to make an informed choice about their health care and, in most instances, must give permission to proceed with treatment. That permission is called informed consent. It is an interactive process between the health practitioner, the person and sometimes those close to the person, such as their family or whānau.

It is the practitioner’s responsibility to ensure informed consent is obtained, and to communicate and work with the person to help them make the best decision for themselves. The practitioner undertaking the treatment is responsible for the overall informed consent process. The person has the right to refuse treatment and withdraw consent. All people are presumed competent to give informed consent unless established otherwise. Verbal informed consent is usually sufficient, (if an early surgical abortion is to be carried out under general anaesthesia written informed consent is required), and should be clearly documented in the clinical notes.

In this video Professor Lynley Anderson of The Bioethics Centre at the University of Otago describes what informed consent is, and why getting it is important.

Further reading and resources:

• The New Zealand Code of Health and Disability Services Consumers’ Rights 1996
• The Medical Council of New Zealand statement “Informed Consent: Helping patients make informed decisions about their care” is part of the Council’s communication and consent standards
• Te Kaunihera Tapuhi o Aotearoa - Nursing Council of New Zealand’s Tikanga Whanonga – Code of Conduct
• A consensus statement on informed consent and decision making from the New Zealand College of Midwives
• The Pharmacy Council of New Zealand Code of Ethics is available as a PDF

Pregnancy options – referral pathways

Decision to continue pregnancy

People who decide to continue with pregnancy should be transferred to Lead Maternity Carer (LMC) care. The “Find Your Midwife” website is a nationwide resource which allows people to select a LMC or a referral from a general practitioner may be required to access local maternity services.

Early pregnancy complications

Refer to the local gynaecology or early pregnancy service. If urgent care is required, refer immediately to the nearest emergency health services.

Ambivalence

Ensure that the pregnant person is aware of their abortion options with reference to gestational age. Suggest that they give themselves more time to make their decision. Make a follow-up appointment and offer pre-decision abortion counselling.

Abortion options and pathways

First trimester options

People requesting an abortion should be offered an informed choice of medical or surgical methods, taking into account the gestational age, their medical history, and local service provision options. Health practitioners also need to ensure that the person’s home setting is suitable and safe, and that they will have access to emergency care if required, before offering an EMA in the home setting. Health practitioners should be well prepared to describe and discuss the options for abortion, communicating clearly in a manner best suited to the individual’s needs. Table 1 is a summary of information that may help people make this decision. The table compares EMA and surgical abortion to 14 weeks and is adapted from Table 2 in Appendix B of the New Zealand Aotearoa Abortion Clinical Guideline 2021.

Table 1. Comparison between medical and surgical abortion (adapted from the New Zealand Aotearoa Abortion Clinical Guideline 2021 – Appendix B, Table 2)

	Medical abortion (to 70 days gestation)	Early surgical abortion (to approximately 14 weeks gestation)
Factor which may inform decision-making	No surgery is required No anaesthesia is required It has potential for greater privacy The procedure is completed by the person It may feel more ‘natural’ (akin to a miscarriage) for some people It will be painful, but pain can be managed with analgesics The person is likely to have heavy bleeding and may see possible evidence of products of conception For EMA, other side effects can include fever, nausea and diarrhoea	The procedure is shorter It is usually less painful as anaesthesia and analgesia are offered beforehand The procedure is completed by a health practitioner It is more effective than medical abortion (less risk of requiring further intervention) An IUC, LNG-IUS or LNG implant can be fitted at the same time There is less bleeding and the person does not have to see any possible evidence of products of conception unless they want to.
Timeframe and follow-up	Duration of abortion can vary. Evidence is the abortion is likely to occur within 4–6 hours of taking the second medicine. However, it is possible that it may take days in extreme circumstances. It is imperative to get the follow-up serum β-hCG test and the result, as it is the only way to know that the abortion is complete and there is no ongoing pregnancy	The procedure itself is completed within 5–10 minutes This is followed by 30–60 minutes of observation time

For further information for people choosing between EMA and surgical abortion in the first trimester, the following websites and resources are recommended:

• DECIDE (Decide.org.nz) is the National Abortion Telehealth Service. The DECIDE website provides user-focused information about the abortion services available in New Zealand, abortion care and how to find a local provider
• International Planned Parenthood Federation (IPPF) has created a visual resource which may be useful for explaining abortion options, e.g. in combination with a translation service, when English is not the person’s first language. There is a small amount of text, and it is currently available in English, French, Spanish, Hindi and Nepalese versions
• IPPF also provides a three-minute surgical abortion explainer video for people considering this option
• An overview table developed in the United States comparing EMA to early surgical abortion is available here

Change of decision to continue pregnancy after beginning the abortion process

People who choose to have an abortion are unlikely to change their mind.

There is no robust data regarding the pregnancy continuation rate after only taking 200 mg of mifepristone (the first medicine taken for EMA, which can also be used for cervical priming in early surgical abortion). It is likely that gestational age impacts outcomes.

There has been a proposal that taking progesterone after mifepristone would reverse the effect of the mifepristone, resulting in higher rates of continuing pregnancy for people who choose not to take the misoprostol. However, there is no evidence to support the safe use of progesterone as abortion reversal. The only randomised controlled trial to investigate this was stopped early due to high rates of significant blood loss with hospital admission for people in both the placebo and progesterone arms of the trial. The conclusion is people who do not take their misoprostol after the mifepristone are at increased risk of heavy bleeding requiring hospital admission.

People who change their minds about wanting an abortion after taking mifepristone need to be provided with evidence-based care to ensure they remain safe and well, including supporting any complications that occur. If someone presents after taking mifepristone and does not wish to continue with their abortion:

• Offer an ultrasound scan to establish if the pregnancy has continued
• Advise that if the pregnancy is seen to be continuing on ultrasound, there is a reasonable chance it will continue. However, there is an increased risk of pregnancy loss later in the pregnancy
• Advise that mifepristone is not known to cause birth anomalies
• Advise that there is no evidence to support treatment with progesterone and it should not be offered
• Offer counselling
• Advise of ongoing pregnancy options including abortion options
• Refer on for antenatal care if indicated

Abortion options after the first trimester

Abortion after 14 weeks is carried out through a surgical procedure (dilation and evacuation, usually under general anaesthetic) or with medicines (in a hospital or specialist clinic setting). Pregnant people with gestational age greater than 14 weeks should be referred to their local or regional abortion service for discussion of these options, taking into account the gestational age, their medical and surgical history, health practitioner skill and local/regional service provision.

Opportunistic STI screening

Practitioners should routinely offer opportunistic testing for chlamydia, and gonorrhoea using a vulvovaginal nuclear acid amplification test (NAAT) swab. This can be performed as part of a pelvic examination or self-collected. It is also advised to offer screening for other sexually transmitted infections following the Aotearoa New Zealand STI Guidelines.

• Ensure informed consent for screening, including pre- and post-test counselling
• Do not delay scheduling the abortion appointment while awaiting swab results
• Treat people who test positive for a STI appropriately following the Aotearoa New Zealand STI Guidelines
• Follow the NZSHS partner notification/contact tracing guidelines

Introduction to contraception options

Peri-abortion contraceptive counselling and contraception provision, especially of long-acting reversible contraception (LARC), is an important part of abortion care to prevent subsequent unplanned pregnancies and provide future contraceptive options. Abortion service providers should be able to offer or facilitate access to all methods of contraception, including LARC, to individuals before they are discharged from the service after abortion. The Ministry of Health document ‘New Zealand Aotearoa’s guidance on contraception’ (2020) provides advice and guidance on contraception counselling and options following abortion.

Contraceptive counselling should be individualised, person focused, non-coercive and tiered whereby the most effective contraceptive options are presented first. Information should be provided about the higher relative efficacy of LARC, including implants and intrauterine methods, compared to user-dependent, shorter-acting methods such as an oral contraceptive pill (OCP). The discussion process should be performed using shared decision making with the choice lying with the person (‘the user is the chooser’).

Provision of contraception should ideally occur at the time of the abortion. Consider providing the emergency contraceptive pill (ECP)/script for the ECP in advance for all patients not using LARC.

Contraceptive implants (Jadelle®) and injectables (Depo Provera®) can be administered as part of an EMA on the day mifepristone is taken. However, practitioners need to explain that having the Depo Provera® injection at the same time as mifepristone may increase the risk of ongoing pregnancy, although overall the risk is low.

Intrauterine contraception (IUC), including levonorgestrel containing intrauterine systems (IUS), should be inserted as soon as possible after an EMA when it is reasonably certain that the person is no longer pregnant. Expulsion rates of IUCs inserted immediately post abortion are higher. However, at six months more people are likely to have an IUC in situ compared to those who have delayed insertion. Abortion service providers should ensure that there are enough staff able to provide IUC or a progestogen-only implant so that individuals who choose these methods and are medically eligible can initiate them immediately after an abortion.

Combined hormonal contraception and POP can be safely started immediately at any time after abortion.

For people having a surgical aspiration abortion, contraception can be started on the day of the procedure. Progestogen implants can be inserted whilst the person is waiting for their procedure or after the procedure, and IUD can be inserted once the uterus has been evacuated. It is important to inform the person that there is a slightly higher expulsion rate of an IUD following a surgical abortion. The optimal length of the IUD strings also needs to be considered carefully as the uterus may involute (decrease in size) after the abortion, causing the strings to become longer. Strings may need to be trimmed and it is important to realise this is not necessarily a sign of a partial expulsion in this situation

Medical eligibility criteria for contraception are provided by;

• Faculty of Sexual and Reproductive Healthcare UK Medical Eligibility Criteria for Contraceptive Use (FSRH UK MEC)
• WHO Medical eligibility criteria for contraceptive use (5th edition 2015)

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