CONTRACEPTION
Abortion Counselling by Nurse Specialists
John R Newton* MD MRCOG David A Iddenden** BSc. MB ChB and Patricia Newton*** SRN
Department of Obstetrics and Gynaecology and The Helen Brook Department of Family Planning King's College Hospital, Denmark Hill, London SE5 9RX England
Abstract This paper describes additional training given to nurse specialists in family planning to cover abortion counselling. The primary counselling was carried out by general practitioners or family planning clinic doctors, following this the patient was referred to hospital for counselling by nurse specialists Of the first 742 patients seen, 3.2% were not pregnant and a further 25 patients (3.4%) decided against termination, 21 after counselling, and 4 because of advanced gestation. The interval between nurse counselling and termination (TOP) was 3 to 9 days, and of 682 TOPS 566 (83%)were in the first trimester. The additional training for nurse specialists prevented the unnecessary wastage of resources as only 42 (5.1%) required a second visit to confirm blood test results, e.g. rubella titres, and only a further 44 (5.3%) required referral to medical social workers. Accepted
for publication
October
2, 1979
* Senior Lecturer: present address Lawson Tait Professor of Obstetrics and Gynaecology, Birmingham Maternity Hospital, Queen Elizabeth Medical Centre, Birmingham B15 2TG ** Senior House Officer *** Nurse Specialist in Family Planning
NOVEMBER 1979 VOL. 20 NO. 5
429
CONTRACEPTION
Introduction In a hospital setting it has been usual for the gynaecologist to provide counselling for patients referred for therapeutic termination of pregnancy (TOP) (1,2). However, in certain specialised centres counselling has been given either by social workers (3,4) or by specially trained lay counsellors (5,6). Recently the extension of the nurses role in family planning has led to nurse specialists in family planning providing an effective and successful service (7,8). This paper describes the additional training of these nurse specialists in family planning to cover abortion counselling, and the integration of this service into the hospital clinics.
Training programme Six nurse specialists in family planning, all of whom had completed at least 2 years of family planning clinic work, were accepted for abortion counselling training. A two-day theoretical course was completed, this covered the following topics: 1.
The interview: techniques, psychological preparation
2.
The aim of counselling
3.
The role of the general practitioner
4.
The role of the gynaecologist
5.
The role of the nurse
6.
The role of the medical social worker
7.
Methods of termination and complications
8.
Contraceptive aftercare
9.
Antenatal care and support
10.
Fostering
11.
Adoption
12.
Genetic counselling
Each lecture was followed by group discussion during which "role In addition the play" of interview situations was encouraged. administrative arrangements for the clinic and family planning followThis up were discussed, and data recording and retrieval described. course was supported by the Area Health Authority in response to the Department of Health and Social Security circular on abortion counselling (9).
430
NOVEMBER
1979VOL.20N0.5
CONTRACEPTION
Patients and clinic structure A daily clinic was organised for abortion counselling: in our previous paper (2) we described the method of referral and the access of the patients to the clinic. Patients has already visited either their general practitioner or a family planning clinic before referral. At the clinic the nurse counsellor first carried out a detailed interview and completed a standardised protocol; this covered a general medical and reproductive history, previous attempts at contraception, current use of contraception, side effects, social stress, family problems and other relevant social data. During this preparation interview,the nurse made sure that the client had all the information she needed to reach a decision; the objective was to reduce the stress of this situation, to allay anxiety and to cover all aspects, risk and benefits of continuing with the pregnancy and an abortion. If at this stage a nurse counsellor felt a medical social worker was needed to obtain further information then the patient was seen immediately. Also the method of contraception to be used after termination was discussed. The gynaecologist then saw the patients with the nurse counsellor, completed a pelvic examination, and after further discussion a decision was reached. Those patients who were for termination had the necessary blood taken immediately, and the hospital bed and date of operation were given to the client. For those continuing with the pregnancy,an antenatal clinic visit was arranged for the following week. Occasionally a repeat counselling visit was needed, and this was made with the same nurse counsellor and doctor for the next week. In cases where pregnancy was in doubt,pregnancy tests or ultrasound screening were arranged for the same day, and in medical cases where further detailed genetic counselling was needed,referral to the appropriate clinic took place. For those patients who were to have a termination,the nurse counsellor continued to discuss "further preparation" for admission. This covered aspects of the implications of admission, the hospital ward, method of termination and anaesthesia, post-operative recovery, when to return home, how to cope and when to return to work. At the same time her family planning follow-up ,appointmentwas made. In addition an open access out-patient clinic was held each week so that those patients with problems after termination could be seen.
NOVEMBER 1979VOL.20NO.S
431
CONTRACEPTION
Results The first 742 referrals seen between January and September, 1978, are presented; of these 24 (3.2%) were not pregnant, 25 (3.4%) decided not to have a termination and to continue with the pregnancy, 11 (1.5%) did not attend hospital for operation after deciding for an abortion Forty-four per and in 682 (91.9%) a termination was carried out. cent were married and 56% were single women; 50.3% (373) were aged between 21 and 30 years, 28.7% (213) were 20 years or younger, 18.3% (136) between 31 and 39 and 2.7% (20) were aged 40 years or over. In 82.5% (612) the source of referral was the general practitioner, 11.3% (84) came from a family planning clinic and 2.8% (18) from our own hospital clinics. Of the 24 patients who were not pregnant,all had had either a positive pregnancy test performed elsewhere or amenorrhoea of more than 8 weeks. In all cases repeat Pregnosticon testing was negative and clinical examination confirmed a non-pregnant state. After counselling by the nurse and doctor,25 patients did not proceed to termination, 20 decided against termination after nurse counselling, in 4 the pregnancy was too far advanced (> 20 weeks) and in 1 case no grounds for termination existed. The usual time interval between counselling and termination of pregnancy was 3 to 9 days, during this time 11 patients did not attend for operation, of these 6 had changed their minds and decided not to have an abortion, 3 had spontaneously miscarried, 1 had an ectopic pregnancy and 1 patient proceeded to a private sector TOP. The country of origin was also recorded; in 57% (422) it was Caucasian, 217 patients (29.2%) were West Indian, 43 (5.8%) African and 25 were Asian. All patients had received primary counselling from their general practitioner or family planning doctor before referral to hospital. Of the 829 consultations,742 (89.5%) only required this one interview. Forty-two patients (5.1%) required a second interview, usually to obtain additional information, e.g. the results of a rubella titre, only 44 (5.3%) required additional counselling from the medical social worker and 1 patient required a further interview with a psychiatrist. Of the total patients seen,742, 44.6% (331) were in their first pregnancy, 147 (19.8%) had had one previous pregnancy, 129 (17.4%) 2 previous pregnancies, 77 (10.4%) 3 and 58 (7.8%) 4 or more pregnancies.
432
NOVEMBER
1979 VOL. 20 NO. 5
CONTRACEPTION
Only 22% (166 patients) had previously had a termination of pregnancy and this was twice as likely to have occurred in a negroid patient, 84 (32% of this population group), than a Caucasian patient, Of the total negroid patients 66 (15% of this population group). seen, 260, only 63 (24%) had been born in England. Table I shows the distribution of the 682 patients who had a termination of pregnancy by age and period of amenorrhoea; only 7.2% (49 patients) were in the second trimester, and 17.0% (116) were less than 8 weeks of pregnancy. In TableIIthe major reasons for termination by age of patient are shown. While it is common for many reasons and factors to determine the overall reason for TOP,the major reason is shown here as "socio-economic" 80.5X, failure of contraception 16.6%, medical reasons 1.4% and here it was mainly infection with rubella or confirmation of a genetic abnormality,or in 10 patients (1.4%) a major psychiatric reason was identified. The indication for termination and current contraception used is shown in TableIII;nearly half (44.4%) were using no contraception, 19.2% were using the sheath, 17.0% (118) had used oral contraception within 3 months of the conception, but only in 21 (3.0%) was the pill being taken during the conception cycle. Sixty-eight patients (9.8%) had used an intrauterine device (IUD) within 3 months of conception, but in only 48 (6.9%) was the IUD in Other patients had used mechanical, place during the conception cycle. chemical or withdrawal methods of contraception. Two patients (0.3%) had previously been sterilised. Table IVshows the previous use of contraception against the method advised at the clinic.
Discussion The word counselling is being increasingly used in many fields of medicine. Counselling in relation to abortion has been discussed at some length (14,15); it may first be a simple information service about methods, where to seek advice, risks and benefits, or it may be a more detailed and time consuming exchange between the client and counsellor. During this exchange the counsellor seeks to achieve six points: to provide support at a critical time, to help the patient reach an unbiased decision, to persuade her of the need for adequate follow-up, to screen out those who need specialist advice, to avoid unnecessary guilt, and to try and devise some general benefit from an otherwise negative human experience (10).
NOVEMBER 1979VOL.20N0.5
433
CONTRACEPTION
Table I. Age and duration of pregnancy at termination
> 8 to 12
Weeks
434
%
No.
119
3.8
193
28.3
9.1
240
2.8
343
50.3
21
3.1
94
0.4
128
18.8
4
0.5
13
0.1
18
2.6
116
17.0
466
7.2
682
No.
Q 20
29
4.3
21-30
62
31-39
Total
> 14 Total
Age
>*40
' 12 to 14
%
No.
NOVEMBER
%
100
1979VOL.20NO.S
181
*
277
558
21-30
Total
20
No.
Age
%
80.5
40.0
26.1
Socio-economic
Table
115
2
0.3
of
for
16.6
contraception
Failure
II. Indication
10
2
3
5
0
No.
Medical
termination
and
age
patient
Psychiatric
of
Total
I
CONTRACEPTION
-
-
-
n
0
N’
-
5
-
m
\9
m
m
d
3
A
d -
d
c-4
m
3
2
01
-3
3
4
-
-
i
m
d
d
0
0
0
0
N
0 -
0
0
0
0
-
-
r(
-3
d
d __
0
0
0
m
r-
0
0
0
2 -
0
0
;
A
0
-
m
-3
d
6 -
-
0
2
N
m
-2 :: r-4
v)
\D
0
0
2
i
0
436
\D
NOVEMBER
0
1979VOL.20N0.5
hi
4
Totals
0
=
100
11.6
9.8
17.0
19.2
44.4
Total
% of
number of patients
693
56
Other methods
118
Oral contraception
68
133
Sheath
IUD
308
no. of Patients
None
Contraception used prior to termination
(239)
34.5
2.1
2.7
5.6
7.5
16.6
(300)
43.3
4.9
4.8
8.2
6.3
19.5
IUD
(19)
2.7
a.7
(60)
0
0
0.1
1.3
1.2
Male
(30)
4.3
0.6
0.1
0.1
1.9
1.6
Female
Sterilisation
4.0
1.6
2.5
1.3
2.5
Injectable
advised by hospital clinic
Oral contraception
Table IV.Contraception
CONTRACEPTION
Previous reports have shown the need for adequate contraceptive advice and counselling, and how this can reduce the incidence of repeat termination (2,4). Lewis &d,(3) showed the importance of a structured preparative interview, using a medical social worker, prior to out-patient TOP and how this could reduce anxiety and fear related to the procedure. Others (5) have shown how lay counsellors can help in the decision process prior to TOP, while in Canada abortion counselling has been suggested as a new role for nurses (16). G. Nurse in her book "Counselling and the Nurse" (13) emphasises the role of the nurse as a counsellor in direct patient care, and this together with preparation of the patient will reduce anxiety and stress. A structured psychological interview (11) can also reduce fear and anxiety related to surgical procedures. It was with these factors in mind that nurse specialists were trained in abortion counselling to achieve two objectives, to impart to the patient in as unbiased a way as possible the answers and information she needed, and to prepare those patients who proceeded to termination of pregnancy for their operation and aftercare. In the National Health Service at present,there is a shortage of staff in many grades, and in an effort to reduce the workload on the department of medical social work,we gave additional training to the nurse specialists. This enabled them to reduce the number of medical social work referrals from more than 50% in 1977 to 5.3% with nurse The importance of one interview and continuity specialists in 1978. of care with the nurse is also valuable as it reduces confusion in an anxious patient. The choice of contraception following TOP is vital, the additional skills of the nurse specialist in family planning (7,g) allow a full discussion on all methods and a logical choice to be made by the client. Counselling is an art like teaching (12), and it is clear from our experience that the counsellors gained considerable expertise during this study, and have now felt able to train other counsellors. Regular group meetings to discuss problem patients played an important part in the continuing education of our nurse specialists. In this series only a single counselling visit was required by 90% of patients, reflecting in part the primary counselling they had received from their general practitioner.
Acknowledgements We wish to thank our other nurse specialists for the help in collecting this data, Mrs. Joan Cave and Mrs. Christine Chalcroft for making all the appointments, and the lecturers who kindly gave their help and support to the training course.
438
NOVEMBER 1979VOL.20NO.S
CONTRACEPTION References 1.
Buckle, A.E.R. and Anderson, M.M. B.M.J. 2, 381 (1972)
2.
Newton, J.R. g
3.
Lewis, S.C., Lal, S., Branch, B. and Beard, R.W.:B.M.J. 4, 606 (1971)
4.
Beard, R.W. -et a1,:B.M.J.1, 418 (1974)
5.
Lieberman, E.J. Counselling Preterm (1971)
6.
B.P.A.S. report (1976)
7.
Newton, J.R. -et a1;B.M.J. 1, 950 (1976)
8.
Newton, J.R. -et aL:Contraception 2,
9.
D.H.S.S. circular on abortion counselling training (1978)
&B.M.J.
3, 280 (1973)
577 (1978)
10.
Simms, M. Report on non-medical abortion counselling Publ. Birth Control Trust (1973)
11.
Reading, A. and Newton, J.R.:Acta Obstet. Gynecol. Stand. 5& 105 (1979)
12.
Vennebles, E. In "Counselling" Publ. National Marriage Guidance Council (1973)
13.
Nurse, G. In Counselling and the Nurse.Publ. H.M. and M. Publishers Ltd., Aylenberg (1975)
14.
Cheetham, J. Unwanted pregnancy and counselling. Routledge and Keegan Paul, London (1977)
15.
Lane Report. Committee of Inquiry into the Working of the Abortion Act, Vols. 1, 2 and 3 H.M.S.O. London (1974)
16.
Easterbrook, B: Anew role for nurses: Con. Nurse 73 (1) 28 (1977)
NOVEMBER 1979VOL.20NO.S
abortion counselling.
439
Abortion Counselling by Nurse Specialists
John R Newton* MD MRCOG David A Iddenden** BSc. MB ChB and Patricia Newton*** SRN
Department of Obstetrics and Gynaecology and The Helen Brook Department of Family Planning King's College Hospital, Denmark Hill, London SE5 9RX England
Abstract This paper describes additional training given to nurse specialists in family planning to cover abortion counselling. The primary counselling was carried out by general practitioners or family planning clinic doctors, following this the patient was referred to hospital for counselling by nurse specialists Of the first 742 patients seen, 3.2% were not pregnant and a further 25 patients (3.4%) decided against termination, 21 after counselling, and 4 because of advanced gestation. The interval between nurse counselling and termination (TOP) was 3 to 9 days, and of 682 TOPS 566 (83%)were in the first trimester. The additional training for nurse specialists prevented the unnecessary wastage of resources as only 42 (5.1%) required a second visit to confirm blood test results, e.g. rubella titres, and only a further 44 (5.3%) required referral to medical social workers. Accepted
for publication
October
2, 1979
* Senior Lecturer: present address Lawson Tait Professor of Obstetrics and Gynaecology, Birmingham Maternity Hospital, Queen Elizabeth Medical Centre, Birmingham B15 2TG ** Senior House Officer *** Nurse Specialist in Family Planning
NOVEMBER 1979 VOL. 20 NO. 5
429
CONTRACEPTION
Introduction In a hospital setting it has been usual for the gynaecologist to provide counselling for patients referred for therapeutic termination of pregnancy (TOP) (1,2). However, in certain specialised centres counselling has been given either by social workers (3,4) or by specially trained lay counsellors (5,6). Recently the extension of the nurses role in family planning has led to nurse specialists in family planning providing an effective and successful service (7,8). This paper describes the additional training of these nurse specialists in family planning to cover abortion counselling, and the integration of this service into the hospital clinics.
Training programme Six nurse specialists in family planning, all of whom had completed at least 2 years of family planning clinic work, were accepted for abortion counselling training. A two-day theoretical course was completed, this covered the following topics: 1.
The interview: techniques, psychological preparation
2.
The aim of counselling
3.
The role of the general practitioner
4.
The role of the gynaecologist
5.
The role of the nurse
6.
The role of the medical social worker
7.
Methods of termination and complications
8.
Contraceptive aftercare
9.
Antenatal care and support
10.
Fostering
11.
Adoption
12.
Genetic counselling
Each lecture was followed by group discussion during which "role In addition the play" of interview situations was encouraged. administrative arrangements for the clinic and family planning followThis up were discussed, and data recording and retrieval described. course was supported by the Area Health Authority in response to the Department of Health and Social Security circular on abortion counselling (9).
430
NOVEMBER
1979VOL.20N0.5
CONTRACEPTION
Patients and clinic structure A daily clinic was organised for abortion counselling: in our previous paper (2) we described the method of referral and the access of the patients to the clinic. Patients has already visited either their general practitioner or a family planning clinic before referral. At the clinic the nurse counsellor first carried out a detailed interview and completed a standardised protocol; this covered a general medical and reproductive history, previous attempts at contraception, current use of contraception, side effects, social stress, family problems and other relevant social data. During this preparation interview,the nurse made sure that the client had all the information she needed to reach a decision; the objective was to reduce the stress of this situation, to allay anxiety and to cover all aspects, risk and benefits of continuing with the pregnancy and an abortion. If at this stage a nurse counsellor felt a medical social worker was needed to obtain further information then the patient was seen immediately. Also the method of contraception to be used after termination was discussed. The gynaecologist then saw the patients with the nurse counsellor, completed a pelvic examination, and after further discussion a decision was reached. Those patients who were for termination had the necessary blood taken immediately, and the hospital bed and date of operation were given to the client. For those continuing with the pregnancy,an antenatal clinic visit was arranged for the following week. Occasionally a repeat counselling visit was needed, and this was made with the same nurse counsellor and doctor for the next week. In cases where pregnancy was in doubt,pregnancy tests or ultrasound screening were arranged for the same day, and in medical cases where further detailed genetic counselling was needed,referral to the appropriate clinic took place. For those patients who were to have a termination,the nurse counsellor continued to discuss "further preparation" for admission. This covered aspects of the implications of admission, the hospital ward, method of termination and anaesthesia, post-operative recovery, when to return home, how to cope and when to return to work. At the same time her family planning follow-up ,appointmentwas made. In addition an open access out-patient clinic was held each week so that those patients with problems after termination could be seen.
NOVEMBER 1979VOL.20NO.S
431
CONTRACEPTION
Results The first 742 referrals seen between January and September, 1978, are presented; of these 24 (3.2%) were not pregnant, 25 (3.4%) decided not to have a termination and to continue with the pregnancy, 11 (1.5%) did not attend hospital for operation after deciding for an abortion Forty-four per and in 682 (91.9%) a termination was carried out. cent were married and 56% were single women; 50.3% (373) were aged between 21 and 30 years, 28.7% (213) were 20 years or younger, 18.3% (136) between 31 and 39 and 2.7% (20) were aged 40 years or over. In 82.5% (612) the source of referral was the general practitioner, 11.3% (84) came from a family planning clinic and 2.8% (18) from our own hospital clinics. Of the 24 patients who were not pregnant,all had had either a positive pregnancy test performed elsewhere or amenorrhoea of more than 8 weeks. In all cases repeat Pregnosticon testing was negative and clinical examination confirmed a non-pregnant state. After counselling by the nurse and doctor,25 patients did not proceed to termination, 20 decided against termination after nurse counselling, in 4 the pregnancy was too far advanced (> 20 weeks) and in 1 case no grounds for termination existed. The usual time interval between counselling and termination of pregnancy was 3 to 9 days, during this time 11 patients did not attend for operation, of these 6 had changed their minds and decided not to have an abortion, 3 had spontaneously miscarried, 1 had an ectopic pregnancy and 1 patient proceeded to a private sector TOP. The country of origin was also recorded; in 57% (422) it was Caucasian, 217 patients (29.2%) were West Indian, 43 (5.8%) African and 25 were Asian. All patients had received primary counselling from their general practitioner or family planning doctor before referral to hospital. Of the 829 consultations,742 (89.5%) only required this one interview. Forty-two patients (5.1%) required a second interview, usually to obtain additional information, e.g. the results of a rubella titre, only 44 (5.3%) required additional counselling from the medical social worker and 1 patient required a further interview with a psychiatrist. Of the total patients seen,742, 44.6% (331) were in their first pregnancy, 147 (19.8%) had had one previous pregnancy, 129 (17.4%) 2 previous pregnancies, 77 (10.4%) 3 and 58 (7.8%) 4 or more pregnancies.
432
NOVEMBER
1979 VOL. 20 NO. 5
CONTRACEPTION
Only 22% (166 patients) had previously had a termination of pregnancy and this was twice as likely to have occurred in a negroid patient, 84 (32% of this population group), than a Caucasian patient, Of the total negroid patients 66 (15% of this population group). seen, 260, only 63 (24%) had been born in England. Table I shows the distribution of the 682 patients who had a termination of pregnancy by age and period of amenorrhoea; only 7.2% (49 patients) were in the second trimester, and 17.0% (116) were less than 8 weeks of pregnancy. In TableIIthe major reasons for termination by age of patient are shown. While it is common for many reasons and factors to determine the overall reason for TOP,the major reason is shown here as "socio-economic" 80.5X, failure of contraception 16.6%, medical reasons 1.4% and here it was mainly infection with rubella or confirmation of a genetic abnormality,or in 10 patients (1.4%) a major psychiatric reason was identified. The indication for termination and current contraception used is shown in TableIII;nearly half (44.4%) were using no contraception, 19.2% were using the sheath, 17.0% (118) had used oral contraception within 3 months of the conception, but only in 21 (3.0%) was the pill being taken during the conception cycle. Sixty-eight patients (9.8%) had used an intrauterine device (IUD) within 3 months of conception, but in only 48 (6.9%) was the IUD in Other patients had used mechanical, place during the conception cycle. chemical or withdrawal methods of contraception. Two patients (0.3%) had previously been sterilised. Table IVshows the previous use of contraception against the method advised at the clinic.
Discussion The word counselling is being increasingly used in many fields of medicine. Counselling in relation to abortion has been discussed at some length (14,15); it may first be a simple information service about methods, where to seek advice, risks and benefits, or it may be a more detailed and time consuming exchange between the client and counsellor. During this exchange the counsellor seeks to achieve six points: to provide support at a critical time, to help the patient reach an unbiased decision, to persuade her of the need for adequate follow-up, to screen out those who need specialist advice, to avoid unnecessary guilt, and to try and devise some general benefit from an otherwise negative human experience (10).
NOVEMBER 1979VOL.20N0.5
433
CONTRACEPTION
Table I. Age and duration of pregnancy at termination
> 8 to 12
Weeks
434
%
No.
119
3.8
193
28.3
9.1
240
2.8
343
50.3
21
3.1
94
0.4
128
18.8
4
0.5
13
0.1
18
2.6
116
17.0
466
7.2
682
No.
Q 20
29
4.3
21-30
62
31-39
Total
> 14 Total
Age
>*40
' 12 to 14
%
No.
NOVEMBER
%
100
1979VOL.20NO.S
181
*
277
558
21-30
Total
20
No.
Age
%
80.5
40.0
26.1
Socio-economic
Table
115
2
0.3
of
for
16.6
contraception
Failure
II. Indication
10
2
3
5
0
No.
Medical
termination
and
age
patient
Psychiatric
of
Total
I
CONTRACEPTION
-
-
-
n
0
N’
-
5
-
m
\9
m
m
d
3
A
d -
d
c-4
m
3
2
01
-3
3
4
-
-
i
m
d
d
0
0
0
0
N
0 -
0
0
0
0
-
-
r(
-3
d
d __
0
0
0
m
r-
0
0
0
2 -
0
0
;
A
0
-
m
-3
d
6 -
-
0
2
N
m
-2 :: r-4
v)
\D
0
0
2
i
0
436
\D
NOVEMBER
0
1979VOL.20N0.5
hi
4
Totals
0
=
100
11.6
9.8
17.0
19.2
44.4
Total
% of
number of patients
693
56
Other methods
118
Oral contraception
68
133
Sheath
IUD
308
no. of Patients
None
Contraception used prior to termination
(239)
34.5
2.1
2.7
5.6
7.5
16.6
(300)
43.3
4.9
4.8
8.2
6.3
19.5
IUD
(19)
2.7
a.7
(60)
0
0
0.1
1.3
1.2
Male
(30)
4.3
0.6
0.1
0.1
1.9
1.6
Female
Sterilisation
4.0
1.6
2.5
1.3
2.5
Injectable
advised by hospital clinic
Oral contraception
Table IV.Contraception
CONTRACEPTION
Previous reports have shown the need for adequate contraceptive advice and counselling, and how this can reduce the incidence of repeat termination (2,4). Lewis &d,(3) showed the importance of a structured preparative interview, using a medical social worker, prior to out-patient TOP and how this could reduce anxiety and fear related to the procedure. Others (5) have shown how lay counsellors can help in the decision process prior to TOP, while in Canada abortion counselling has been suggested as a new role for nurses (16). G. Nurse in her book "Counselling and the Nurse" (13) emphasises the role of the nurse as a counsellor in direct patient care, and this together with preparation of the patient will reduce anxiety and stress. A structured psychological interview (11) can also reduce fear and anxiety related to surgical procedures. It was with these factors in mind that nurse specialists were trained in abortion counselling to achieve two objectives, to impart to the patient in as unbiased a way as possible the answers and information she needed, and to prepare those patients who proceeded to termination of pregnancy for their operation and aftercare. In the National Health Service at present,there is a shortage of staff in many grades, and in an effort to reduce the workload on the department of medical social work,we gave additional training to the nurse specialists. This enabled them to reduce the number of medical social work referrals from more than 50% in 1977 to 5.3% with nurse The importance of one interview and continuity specialists in 1978. of care with the nurse is also valuable as it reduces confusion in an anxious patient. The choice of contraception following TOP is vital, the additional skills of the nurse specialist in family planning (7,g) allow a full discussion on all methods and a logical choice to be made by the client. Counselling is an art like teaching (12), and it is clear from our experience that the counsellors gained considerable expertise during this study, and have now felt able to train other counsellors. Regular group meetings to discuss problem patients played an important part in the continuing education of our nurse specialists. In this series only a single counselling visit was required by 90% of patients, reflecting in part the primary counselling they had received from their general practitioner.
Acknowledgements We wish to thank our other nurse specialists for the help in collecting this data, Mrs. Joan Cave and Mrs. Christine Chalcroft for making all the appointments, and the lecturers who kindly gave their help and support to the training course.
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CONTRACEPTION References 1.
Buckle, A.E.R. and Anderson, M.M. B.M.J. 2, 381 (1972)
2.
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3.
Lewis, S.C., Lal, S., Branch, B. and Beard, R.W.:B.M.J. 4, 606 (1971)
4.
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8.
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9.
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577 (1978)
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Simms, M. Report on non-medical abortion counselling Publ. Birth Control Trust (1973)
11.
Reading, A. and Newton, J.R.:Acta Obstet. Gynecol. Stand. 5& 105 (1979)
12.
Vennebles, E. In "Counselling" Publ. National Marriage Guidance Council (1973)
13.
Nurse, G. In Counselling and the Nurse.Publ. H.M. and M. Publishers Ltd., Aylenberg (1975)
14.
Cheetham, J. Unwanted pregnancy and counselling. Routledge and Keegan Paul, London (1977)
15.
Lane Report. Committee of Inquiry into the Working of the Abortion Act, Vols. 1, 2 and 3 H.M.S.O. London (1974)
16.
Easterbrook, B: Anew role for nurses: Con. Nurse 73 (1) 28 (1977)
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abortion counselling.
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