Standard of Care for Abortion

Thomas W. Strahan Memorial Library
Index
Standard of Care for Abortion
Abortion Decision-Making
Psychological Effects of Abortion
Social Effects and Implications
Physical Effects of Abortion
Abortion and Maternal Mortality
Adolescents and Abortion
Definition of Terms
Women's Health After Abortion
Material Yet to be Cataloged
Strahan Summary Articles

Section 1

Abortion Procedures - Standards and Guidelines

“ National Abortion Federation. 1998 Clinical Policy Guidelines in A Clinician’s Guide to Medical and Surgical Abortion, Ed. Maureen Paul et al (New York: Churchill Livingston, 1999) 255-269

Supercedes 1.1.9 Standards for Abortion Care: National Abortion Federation (1986)

Guidelines for Women's Health Care,(Washington D.C.: The American College of Obstetricians and Gynecologists, 1996)

This publication provides comprehensive information on a wide range of ob/gyn subjects including abortion. The guidelines state that "properly performed abortion poses minimal risk to women." Further that "All legal requirements must be met, and clinicians who perform abortions should be aware of state statutes and regulations regarding abortion services."

"Medical Management of Abortion," ACOG Practice Bulletin. Clinical Management Guidelines for Obstetricians-Gynecologists, No. 26, April, 2001

Guidelines regarding use of Mifepristone, Methotrexate and Misoprostol for induced abortion.

"Antibiotic Prophylaxis for Gynecologic Procedures," . ACOG Practice Bulletin. Clinical Management Guidelines for Obsterician-Gynecologists, Number 23, January, 2001

Recommends tetracyclines and nitro-imidazoles for induced abortion and dilation and curettage.

Abortion Practice, Warren M. Hern M.D., Director, Boulder Abortion Clinic, (Boulder, Colorado: J.B. Lippincott Co., 1981, 1984, 1990).

An abortion service that provides no counseling at all is seriously deficient ... Training of counselors should include a minimum of 16 hours each of medical training and counseling techniques. Medical training should include reviews of reproductive anatomy and physiology, gynecologic diseases, venereal disease, breast and cervical cancer, sterilization, medical aspects of abortion, theory and case studies of oral contraceptives and intrauterine devices and conventional contraceptive methods. There should be a continuous inservice training program on the medical and psychological aspects of abortion. The Carkhuff method of empathy training is extremely helpful in abortion counseling. ... Individual counseling is time consuming and expensive, but it affords a better opportunity for patient evaluation and careful instruction. Group counseling is better than no counseling at all. To permit thorough questioning and full participation, groups should not exceed three or four patients ... There should be ample opportunity for those accompanying the patient to participate, with the patient's consent, during the portions of the counseling dealing with the abortion procedure and contraceptive methods. Arrangements for separate counseling should also be available.... Counseling should include the following: Social history relevant to the abortion, including feelings about pregnancy and abortion, brief explanation of reproductive anatomy and physiology, explanation of the abortion procedure and use of laminaria, discussion of birth control methods, presentation of the consent form for review by the patient.

"Standards for Obstetric-Gynecologic Services," The American College of Obstetricians and Gynecologists (Washington, D.C.: Committee on Professional Standards, 1981).

Policies covering abortions should be designed by the medical staff to guard the patient's health or improve the family life situation. Abortion is a surgical procedure. For its performance, adequate facilities, equipment and personnel are required to assure the highest standards of patient care. ... It is recognized that although an abortion may be requested by a patient or recommended by a physician, the final decision as to performing the abortion must be left to the medical judgment of the pregnant woman's attending physician, in consultation with the patient. No physician should be required to perform, nor should any patient be forced to accept an abortion. The usual informed consent, including operative permit, should be obtained. The same indications for consultation should apply to abortions as to other medico surgical procedures. Abortions should be performed only by physicians qualified to identify and manage complications that may arise from the procedure. pp. 64-65 (Most courts consider that the patient is "informed" if the following information is given: The processes contemplated by the physician as treatment, including whether the treatment is new or unusual; the risks and hazards of the treatment; the chances for recovery after treatment; the necessity of the treatment; the feasibility of alternative methods of treatment. There are two major exceptions to informed consent before treating a patient, i.e., emergency treatment and detriment to patient (therapeutic privilege). Therapeutic privilege can never be construed to allow a physician to misrepresent the facts and to state affirmatively that there is no danger when in fact great danger exists. The following reasons are not sufficient to justify failure to inform: [1] That the patient may prefer not to be told unpleasant possibilities regarding the treatment; (2] Full disclosure might suggest infinite dangers to a patient with an active imagination thereby causing her to refuse treatment; (3] That the patient, on learning the risks involved, might rationally decline treatment. The right to decline is the specific fundamental right protected by the informed consent doctrine. (It is advisable to get a written consent. In addition, it is suggested that a physician make a written notation on the patient's record indicating the information communicated.) pp-66-67

Standards for Obstetric-Gynecologic Services 7th Edition, The American College of Obstetricians and Gynecologists, College of Obstetricians and Gynecologists, 409 12th St. S.W. Washington D.C. 20024-2188 (1989).

This publication includes detailed standards for ambulatory care for obstetrics and gynecology and specifically states "Ambulatory care facilities should meet the same standards of care for abortion facilities as for other surgical procedures." p. 68.

Ambulatory Maternal Health Care and Family Planning Services Policies. Principles. Practices, ed. Florence E.F. Barnes, Committee on Maternal Health Care and Family Planning, Maternal and Child Health Association, American Public Health Association, Interdisciplinary Books and Periodicals For the Professional and the Layman (1978).

Community efforts are needed to assure that abortion services meet high standards. Prospective abortion patients usually want greater confidentiality for this procedure than for most other medical services. Thus the woman is in a peculiarly vulnerable position because she may be reluctant to complain to any authority concerning the quality of service received. Since a woman will probably require this service only once in her life, she has no option to change providers as a result of her experience. In addition, she has a very limited time to find appropriate services and to learn anything about the quality of providers before her pregnancy advances to a state where the risks, costs, and psychological impact of abortion are substantially increased. p. 45

The basic principles of abortion counseling are [1] counseling should be entered into freely; [2] it should be supportive and non-judgmental regardless of the circumstances of the pregnancy, and [3] it should be an educational experience. The aims of abortion counseling are [1] to aid the woman in reaching a decision considering such factors as relationships to family and others, the future of the infant if she were to carry it to term, the impact of the pregnancy and a child on her own educational and vocational goals and economic situation; [2] to help her implement whatever decision she makes; and [3] to offer assistance in controlling future pregnancies.

There should be written criteria to serve as a guide in the counseling process for caution, postponement, or rejection of a patient in an ambulatory facility. Counseling should be so timed and arranged that it need not be cut short in order for the physician to proceed with the abortion. It is recommended that counseling take place the day before, or if possible, two to three days before the scheduled operative time so that an ambivalent patient may have time to assimilate new information, talk with family or partner, if appropriate, and reflect on her decision. Overall content of counseling in the facility should cover: [1] Financial arrangements. [2] Alternative arrangements of handling the pregnancy. [3] Reproductive and contraceptive history by interview or self taken history. [4] Relevant medical history by interview or self-taken history. [5] Relevant social history by interview or self-taken history. [6] Discussion and information on sexuality and sexual behavior as appropriate. [7] Information and instructions regarding the examination, abortion, postoperative care, symptoms of trouble, where to call for post procedure help. [8] Informed consent process. [9] Contraceptive counseling and information.

"Administrative. Counseling and Medical Practices in National Abortion Federation Facilities," U. Landy and S. Lewit, Family Planning Perspectives 14(5): 257-262, Sept/Oct 1982.

Summarizes the counseling standards of National Abortion Federation facilities. Reported that 70% of the women came to NAF facilities without referral from a doctor.

"Standards For Abortion Care," National Abortion Federation, 900 Pennsylvania Ave. S.E. Washington D.C. 20003. (Revised November 1986).

Procedural and substantive standards for members of the National Abortion Federation. These standards are now out of date and have been replaced by NAF clinical policy guidelines.

Obstetrical Decision Making, Second Edition, Eds. Emanuel A. Friedman, David B. Acker, Benjamin P. Sachs, (Philadelphia: B.C. Decker, 1987).

The editors of this text are on the staff of Beth Israel Hospital and Professors or Assistant Professors at Harvard Medical School. It also includes a series of articles written by other authors. "Induced Abortion," Max Borten M.D. "It is essential for the gravida to be fully informed about alternative resources and options and about the safety and risks of the procedure. Psycho-social assessment and counseling are done at the very first step. In addition to the medical history, an in depth social history including relationships with others, attitudes about abortion, and support systems must be obtained at this time. Pre- abortion counseling should be open and understanding. No decision should be made by the gravida in haste, under duress, or without adequate time and information. Special attention should be given to feelings of ambivalence, guilt, anger, shame, sadness, and sense of loss. Family supports, if available, should be mobilized. Postoperative contraception must be emphasized. Counseling should also be done prior to the procedure and again during the follow-up visit." p. 44. A valuable flow chart is included. See also "Psycho-social Assessment," Patricia S. Stewart, M.S., M.S.W., describing the basic elements of psycho-social assessment, p. 301.

"Ethical Issues in Clinical Obstetrics and Gynecology," Benjamin Freedman, Current Problems in Obstetrics, Gynecology and Fertility, ed. John M. Leventhal, 8(3): 1-47, (Chicago: Year Book Medical Publishers, 1985).

Extended ethical discussion of important topics, including physician's authority, goals of treatment, information and truth telling, counseling, duties to others, family, physician autonomy.

"The Hippocratic Oath," trans. W.H.S. Jones, Child and Family Quarterly 2(2) (1972)

See also Declaration of Geneva, adopted by the World Medical Association in 1948, which attempted to update the Hippocratic Oath, pp. 98-99. For comment on the Hippocratic Oath, see Child and Family Quarterly, 10(l):2-3 (1971) and Linacre Quarterly45(2): 106 (May 1978).

"The Hippocratic Oath: A Code for Physicians, not a Pythagorean Manifesto," P. Prioreschi, Medical Hypotheses 44: 447-462, 1995

The Hippocratic Oath is to be considered a code of conduct for all physicians and not a Pythagorean Manifesto. Many of the principles upheld by the Oath are found in other documents unrelated to the Pythagoreans.

Informed Consent

“Informed consent is a legal and ethical obligation…Informed consent includes informing the patient about her medical condition, available treatment options, and the benefits and risks of these alternatives……

…the woman should initially be questioned alone about her decision and afforded an opportunity to disclose coercion. If a patient expresses doubts or misgivings, her options and feelings warrant more extensive exploration.”

The above passage is from the chapter on “Informed consent, patient education and counseling” which appears in a recent edition of the leading textbook on abortion care in the United States, Management of unintended and abnormal pregnancy.

Standard for Medical Disclosure of Risks and Benefits

The U.S. Preventive Services Task Force (USPSTF) within the Agency for Healthcare Research and Quality, which is a division of the U.S. Department of Health and Human Services (http://www.ahrq.gov/clinic/3rduspstf/ratings.htm), has identified basic guidelines for how scientific evidence should be used to inform practice. These are summarized below and are based on an analysis of risks and benefits as established in the scientific literature.

• Level A: Good scientific evidence indicates the benefits of the service substantially outweigh the risks with clinicians advised to discuss the service with eligible patients.
• Level B: Fair scientific evidence indicates the benefits of the service outweigh the risks with clinicians encouraged to discuss the service with eligible patients.
• Level C: At least fair scientific evidence indicating benefits are provided by the service, but the balance between benefits and risks precludes general recommendations.

Clinicians are advised to only offer the service if there are special considerations.

• Level D: At least fair scientific evidence indicates the risks of the service outweigh benefits with clinicians advised not to routinely offer the service.
• Level I: Scientific evidence is deficient, poorly done, or conflicting precluding assessment of the risk benefit ratio. Clinicians are advised to convey the uncertainty of evidence surrounding the service to patients.

Given these guidelines, it is clear that responsible physicians should not be routinely offering abortion. The best published evidence shows clear risks associated with abortion but no clear benefits, meaning that Level's D and I are most applicable.

Distortions of Informed Consent

"The federal government and academic texts as barriers to informed consent." Lanfranchi, A. J Amer Phys & Surg. V13,N1:12-15. Spring 2008.

This is an excellent review of the history of government agencies and academic sources which have politicized the interpretation of scientific literature in order to obscure public notice of information that may undermine public policies. Examples regarding the links between breast cancer and oral contraception and abortion are examined.

Relevant Court Rulings

"Akron v. Akron Center for Reproductive Health," 462 U.S. 416, 445(1983).

"A state may require that a physician make certain that his patient understands the emotional and physical implications of having an abortion."

"Planned Parenthood of Central Missouri v. Danforth," 428 U.S. 52, 67(1976).

A state may require informed consent even in the first trimester.

"Planned Parenthood of S.E. Pa. v. Casey," 505 U.S. 112 S. Ct. 2791 (1992)

Upheld a state statute requiring disclosure of the nature of the abortion procedure, the risks of the procedure, the alternatives to the procedure, the gestational age of the unborn child and the medical risks of carrying to term. If a woman so requests, she must be given a state department of health brochure describing fetal development and a list of agencies offering alternatives to abortion.

"Wilson v. Scoll," 412 SW2d 299(1967)

Disclosure to patient is required if there is a 1% risk of hearing loss.

"Cobbs v. Grant," 8 Cal 3rd 229, 502 P2d 1(1972)

Good general discussion of disclosure requirements.

"Reynier v. Delta Women's Clinic," 359 So2d 733 (La. App. 1978)

An abortionist was not liable on a theory of lack of informed consent as there was no showing that the plaintiff would not have obtained the abortion if the risk were known.

Other Sources

"Informed Consent in Crisis Pregnancy and Abortion," W Brett and A Brett, Journal of Christian Health Care 5(1): 3-10, March, 1992.

Discusses autonomy, veracity, justice, beneficence and non-maleficence. During pregnancy and perinatal medicine, issues of consent may be especially difficult and complex, particularly when the pregnancy produces a life crisis or when induced abortion is considered.

"Ethical Dimensions of Informed Consent," American College of Obstetricians and Gynecologists, Women's Health Issues 3(1): 1-10, Spring, 1993

Comprehensive statement on the various aspects of informed consent with commentary.

"Misrepresentation or Ignorance of Fetal Development as a Factor in Psychological Injury Following Induced Abortion," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change 9(4):l-8, May/June 1996

Accurate information on fetal development is relevant and material to informed consent prior to induced abortion.

"Lack of Individualized Counseling Regarding Risk Factors For Induced Abortion: A Violation of Informed Consent," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change 10(1): 1-8 July/August 1996

The likelihood of post-abortion infections, perforation of the uterus, or missed abortion varies greatly among individual women obtaining induced abortion.

"Lack of Individualized Counseling Regarding Risk Factors For Induced Abortion: A Violation of Informed Consent. Part 2," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change 10(2): 1-8, Sept/Oct, 1996

The incidence of incomplete abortion, cervical injury, bleeding or hemorrhage, pain, adverse reproductive effects and psychological problems following induced abortion varies greatly among individual women obtaining induced abortions.

"Abortion and Informed Consent: A Cause of Action," Joseph Stuart, Ohio Northern Univ. Law Review, 14(I): 1-20, (1987)

The right to decide to have an abortion in consultation with a physician is one that can be truly exercised only if the pregnant woman has full knowledge of the abortion procedure, its risks and alternatives, as well as a description of who or what is to be aborted.

"Informed Consent: 1. II. III," Jeslie J. Miller, Journal of the American Medical Association 244 (18): 2100, Nov. 7, 1980; JAMA 244 (20): 2347, Nov. 21, 1980: JAMA 244(22): 2556, Dec. 5, 1980

Good overview of the law of informed consent.

"Counseling, consulting and abortion," Mary Anne Wood and W. Cole Durham, Jr. Brigham Young University Law Review 1978, 783-845

States may wish to pay greater attention to civil remedies that would provide compliance incentives in the area of informed consent.

"Informed Consent to Abortion: A Refinement," T.L. Jipping, Case Western Reserve Law Review 38:329-386 (1987/88)

Reviews inconsistencies in the U.S. Supreme Court decisions involving informed consent. Suggests that informed consent law should focus on the woman, not the doctor, that the reasonable patient model should be followed, and that a definition of health should be used consistent with the breadth given to health when the abortion right was established.

"Informed Consent and the Danger of Bias in the Formation of Medical Disclosure Practices," Schneyer, Wisconsin Law Review 124 (1976)

Good general summary; no specific mention of abortion.

"Current Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association," (1988), Informed Consent (8.08)

Informed consent is a basic social policy for which exceptions are permitted (1) When the patient is unconscious or otherwise incapable of consenting and harm from failure to treat is imminent, or (2) When risk disclosure poses such a serious psychological threat of detriment to the patient as to be medically contraindicated. Social policy does not accept the paternalistic view that the physician may remain silent because divulgence might prompt the patient to forgo needed therapy. Rational, informed patients should not be expected to act uniformly even under similar circumstances in agreeing to or refusing treatment.

"Uninformed Consent and Terms Without Definitions," Joseph E. Hardison, American Journal of Medicine 74:932-933, June, 1983

During the time of denial, turmoil and intense personal loss and grief, it is understandable that many patients may give uninformed consent. Forcing the patient to face reality may precipitate panic, psychosis or suicide. We must give time to help them adjust to what is wrong before consent is meaningfully and truly informed.

"Abortion Legislation After Webster v. Reproductive Health Services: Model Statutes and Commentaries," David M. Smolin, Cumberland Law Review 20:71, 141, (1989-90)

In an investigation of abortion facilities a Miami Herald reporter posing as a potential client in a Florida abortion clinic said "What about the baby. I'm worried about hurting the baby." "What baby', answered the clinic owner. There's just two periods there that will be cleared out." "You mean I'm not pregnant?" Oh, you're pregnant. But there is no baby there... two periods and some water. If you don't terminate, then it will become a fetus, and after birth it will become a baby." Quoting Sontag, "An Abortion," Miami Herald, Sept 17, 1989, Tropic at pg. 14 "The Woman's Right to Know: A Model Approach to the Informed Consent of Abortion," S.A. Oliver, R. Shaheen, M. Hegarty, Loyola University of Chicago Law Journal 22(2): 409, Winter, 1991

"Informed Consent Civil Actions for Post Abortion Psychological Trauma," Thomas E. Eller, Notre Dame Law Review 639, 1996

"The link between the elements for an informed consent cause of action and the scientific evidence linking induced abortion with increased breast cancer risk," J Kindley, Wisconsin Law Review 1595-1644, 1998

"Fetal Development Information: An Essential Aspect of Informed Consent," Monte Liebman, Association for Interdisciplinary Research Newsletter 3(1): 1-2, Spring, 1990

If people were informed that the life of a human individual is eliminated by abortion, then many would freely choose to forego the abortion) (It is not irrational to be fearful of terminating another's life, that is human.

Aborted Women: Silent No More, David C. Reardon, (Chicago: Loyola Univ. Press, 1987)

In every one of the thousands of cases documented by Women Exploited by Abortion, a full explanation of the possible risks and complications was not given by the abortion provider. Even when direct questions were asked, answers about risks are understated, construed or avoided. Rather than risks, alternatives or fetal development, abortion counseling is generally devoted to discussing birth control techniques.

"A New Problem in Adolescent Gynecology," M. Bulfin, Southern Medical Journal 72 (8):967-968, August 1979.

Fifty-Four teenage patients were seen with significant complications after legal abortion. None felt they had been afforded any meaningful information about the potential dangers of the abortion operation. Perforation of the uterus, peritonitis, pelvic pain, pelvic abscesses, bleeding and cramping, cervical lacerations, severe hemorrhage and adverse psychological and psychiatric sequelae were noted in various case reports.

"Physical and Psychological Injury in Women Following Abortion: Akron Pregnancy Services Survey," L.H. Gsellman Association for Interdisciplinary Research Newsletter, 5(4):l-8, Sept/Oct 1993.

In a retrospective study of post-abortional women at an Ohio pregnancy services center only about one-half said they had been adequately informed about fetal development or possible psychological and/or physical complications.

"Regulating Abortion Services," (letter), Virginia P. Riggs, New England Journal of Medicine, February 7, 1980, p. 350.

A description of the fetus is relevant to a woman's decision about abortion... To claim that this information does not pertain directly to the abortion procedure is to deny any possibility that a second being is involved. Women deserve to know exactly what would be removed before they make a decision. The doctor who protects them from the facts to preserve them from anxiety and guilt has made a moral decision on their behalf.

"Crisis and Informed Consent: Analysis of a Law-Medical Malocclusion," Fran Camerie, American Journal of Law and Medicine 12:54-97, 1986

People in crisis states undergo psychological and cognitive changes which temporarily impede their ability to render an informed and rational decision, yet do not render them incompetent.

"The "Exceptions" to the Informed Consent Doctrine: Striking a Balance Between Competing Values in Medical Decision-Making," Alan Meisel, Wisconsin Law Review, 413, 1979

Discusses the interests of the individual, family and friends, society, the professions, the nature of the decision, waiver, voluntariness, incompetency, therapeutic privilege, and decision-making by others; critical of therapeutic privilege.

“Demoralization; its impact on informed consent and medical care”, DW Kissane, Med J Australia 175(10:537, Nov 19, 2001

Demoralization, a mental state characterized by hopelessness and meaninglessness, can interfere with a person’s capacity to give informed consent.

Studies Showing Dangers of Inadequate Screening and Counseling

"Inadequate Preabortion Counseling and Decision Conflict as Predictors of Subsequent Relationship Difficulties and Psychological Stress in Men and Women" Catherine T. Coyle, Priscilla K. Coleman, and Vincent M. Rue, Traumatologyfirst published on November 16, 2009 as doi:10.1177/1534765609347550

(Abstract)The purpose of this study was to examine associations between perceptions of preabortion counseling adequacy and partner congruence in abortion decisions and two sets of outcome variables involving relationship problems and individual psychological stress. Data were collected through online surveys from 374 women who had a prior abortion and 198 men whose partners had experienced elective abortion. For women, perceptions of preabortion counseling inadequacy predicted relationship problems, symptoms of intrusion, avoidance, and hyperarousal, and meeting full diagnostic criteria for posttraumatic stress disorder (PTSD) with controls for demographic and personal/situational variables used. For men, perceptions of inadequate counseling predicted relationship problems and symptoms of intrusion and avoidance with the same controls used. Incongruence in the decision to abort predicted intrusion and meeting diagnostic criteria for PTSD among women with controls used, whereas for men, decision incongruence predicted intrusion, hyperarousal, meeting diagnostic criteria for PTSD, and relationship problems. Findings suggest that both perceptions of inadequate preabortion counseling and incongruence in the abortion decision with one’s partner are related to adverse personal and interpersonal outcomes. :