When Abortion is Not Available

This is a new video series on key topics for learners training in a state where in-clinic abortion is difficult or impossible to access or when patients choose to self-manage their abortions.

Abortion is a common experience and happens at similar rates in most communities, regardless of the legal restrictions in place. This video series contextualizes the ethical and clinical considerations for clinicians and learners living in states or communities where abortion is highly restricted or inaccessible.

For more resources and citations open the dropdown for each video and click on the video title in the light blue box!

If you would like to be able to assign this content to learners and track their progress, you can request a login for RHEcourse, our free online platform for SRH education, which offers additional features for users who want to engage more deeply. If you are a learner who would like to enroll in these courses for self-paced learning, you can request a RHEcourse login for self-paced learning.

Course Development & Description

This curriculum, curated by Dr. Jody Steinauer, MD, PhD (she/her) was created in collaboration with 4 experts on abortion from a range of professions and disciplines:

  • Ana Delgado, CNM, MS (she/her) is a midwife, abortion provider, educator, and community activist.
  • Teresa DePiñeres, MD, MPH (she/her) is an ob-gyn physician, specialized in complex family planning and abortion, and an expert in international sexual and reproductive health, as well as a mentor and coach.
  • Bhavik Kumar, MD MPH (he/him) is a family medicine physician, specialized in complex family planning and abortion, providing abortion care, gender care, and primary care.
  • Biftu Mengesha, MD, MAS (she/her) is an ob-gyn physician, specialized in complex family planning and abortion, and director of Innovating Education in Reproductive Health.

The four videos in this series provide an overview of the key information about abortion that all clinicians and clinical learners need to know, regardless of the legal status or availability of abortion in their community. Each core video is followed by key resources and additional videos to guide additional learning about clinical care, abortion research, legal restrictions.

For more resources and citations open the dropdown for each video and click on the video title in the light blue box!

Learning Objectives

Course learning objectives

After taking this course a learner will be able to:

  1. Explain that abortion is a safe, essential component of comprehensive healthcare and identify common obstacles that limit safe and equitable abortion access.
  2. Recognize that people have the fundamental right to accurate information about abortion and that healthcare providers are professionally obligated to provide accurate information, protect patient confidentiality, and not criminalize patients for their reproductive decisions.
  3. Describe the differences between clinically safe and unsafe abortion, regardless of legal status, and identify inequities in access to safe abortion, particularly for marginalized communities.
  4. Articulate the ethical responsibilities of providers to provide compassionate, non-judgmental care to patients after a self-managed abortion.
  5. Describe the similarities in clinical care for patients after self-managed abortion and general bleeding in early pregnancy.

 

Abortion Is Essential Healthcare

Learning Objectives

After watching this video a learner will be able to:

  • Describe a model of full-spectrum reproductive health care that integrates abortion alongside other essential services.
  • Identify three obstacles that limit access to abortion care.
  • Describe the consensus of national and international organizations regarding the safety of abortion.

When Abortion is Not Available: Abortion is Essential Healthcare

Presented by Ana Delgado, CNM (she/her)

Supplemental Video Content

EXPLAINED: Abortion Safety in the United States Lecture
EXPLAINED: Targeted Regulation of Abortion Providers Lecture

Resources

Safe abortion: technical and policy guidance for health systems

ACOG Committee Opinion 612

ACGME Clarification on Requirements Regarding Family Planning

The International Federation of Gynecology and Obstetrics

World Health Organization

Citations

  1. National Academies of Sciences, Engineering, and Medicine. 2018. The Safety and Quality of Abortion Care in the United States. Washington, DC: The National Academies Press. https://doi.org/10.17226/24950.
  2. Abortion training and education. Committee Opinion No. 612. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;124:1055–9. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2014/11/abortion-training-and-education
  3. ACGME Clarification on Requirements Regarding Family Planning and Contraception. Accreditation Council for Graduate Medical Education, 2017. http://www.acgme.org/portals/0/pfassets/programresources/220_obgyn_abortion_training_clarification.pdf

Reflection Questions

  • Why might patients prefer to access abortion and other pregnancy care services from the same provider?
  • What are elements of full-spectrum reproductive health care that you could implement in your practice? How would this affect patient care?

Healthcare Provider Responsibilities

Learning Objectives

After watching this video a learner will be able to:

  • Situate the right to accurate information about health, including abortion, as a human right held by people across countries regardless of local laws.
  • Recognize the obligations of healthcare providers to convey information about abortion regardless of their personal beliefs.
  • Name 2 reasons why health care providers should not report patient behaviors to the criminal justice system.
  • Describe how the Iniciativas Sanitarias program in Uruguay used a harm reduction model as a way to reduce abortion morbidity and mortality.

Reflection Questions

  • How does the human rights framework address access to abortion? Is abortion treated as a human right in your practice setting?
  • What are the policies and protocols in your practice regarding involving patients in the criminal justice system? How might they affect the lives of your patients?

Self-management of Abortion

Learning Objectives

After watching this video a learner will be able to:

  • List two ways that legal restrictions on abortion make it hard for patients to access needed care and particularly affect marginalized communities.
  • Define the differences between clinically unsafe and safe abortion, regardless of legal status.
  • Recognize that clinicians are under no obligation to call law enforcement and doing so is a violation of patient privacy.
  • Recognize the role of clinicians in preventing the criminalization of pregnant people who self-manage their abortions.
  • Explain the obligations of healthcare providers to support patients who seek abortion outside of the healthcare system with information about what to expect.

When Abortion is Not Available: Self-management of Abortion

Presented by Bhavik Kumar, MD, MPH (he/him)

Supplemental Video Content

Global Obstacles to Abortion

Guidelines for Safe Abortion Care

EXPLAINED: Abortion Safety in the United States Lecture

Additional Resources

Access, Delivered: A Toolkit for Providers Offering Medication Abortion

IPAS Abortion Self-Care

IPAS Medical Abortion and Self-Managed Abortion Human Rights

Eukiapp

Women Help Women

Women on Web

American Bar Association’s resolution opposes criminalization of abortion or miscarriage

Citations

  1. An Overview of Abortion Laws. Guttmacher 2020. https://www.guttmacher.org/state-policy/explore/overview-abortion-laws#
  2. Singh S, Remez L, Sedgh G, Kwok L, Onda T. Abortion Worldwide 2017: Uneven Progress and Unequal Access. Guttmacher 2018. https://www.guttmacher.org/report/abortion-worldwide-2017
  3. Donovan Self-Managed Medication Abortion: Expanding the Available Options for U.S. Abortion Care. Guttmacher 2018; 21.
  4. Jones R, Donovan M. Self-managed abortion may be on the rise, but probably not a significant driver of the overall decline in abortion. Guttmacher 2019. https://www.guttmacher.org/article/2019/11/self-managed-abortion-may-be-rise-probably-not-significant-driver-overall-decline
  5. Self-Managed Abortion- What Healthcare Workers Need to Know. Bixby Center for Global Reproductive Health, Advancing New Standards in Reproductive Health.
  6. Baker C. Self-Managed Abortion Is Medically Very Safe. But Is It Legally Safe? MS Magazine 2020. https://msmagazine.com/2020/04/01/self-managed-abortion-is-medically-very-safe-but-is-it-legally-safe/
  7. Worldwide, an Estimated 25 Million Unsafe Abortions Occur Each Year. Guttmacher and WHO News Release, 2017. https://www.guttmacher.org/news-release/2017/worldwide-estimated-25-million-unsafe-abortions-occur-each-year
  8. Harris L, Grossman D. Complications of Unsafe and Self-Managed Abortion. N Engl J Med 2020; 382:1029-1040 https://pubmed.ncbi.nlm.nih.gov/32160664/
  9. Statement on Decriminalization of Self-Induced Abortion. ACOG 2017. https://www.acog.org/clinical-information/policy-and-position-statements/position-statements/2017/decriminalization-of-self-induced-abortion
  10. Fulfilling Roe’s Promise: 2019 Update. If/When/How 2019. https://www.ifwhenhow.org/resources/roes-unfinished-promise-2019-update/
  11. When Self-Abortion is a Crime. National Institute for Reproductive Health 2017. https://www.nirhealth.org/decriminalize/
  12. World Health Organization. (2012) Safe abortion: technical and policy guidance for health systems – 2nd ed. https://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf?sequence=1

Reflection Questions

  • Are the definitions of safe and clinically unsafe abortion new to you? If so, how do they differ from your formal education and training?
  • How can you support patients who managed their own abortions in your practice?

Caring for Patients After Self-management of Abortion

Learning Objectives

After watching this video a learner will be able to:

  • Name the principles of professional ethics that support patient autonomy and confidentiality when patients present for care after self-managing abortion.
  • Recognize that clinicians are under no obligation to report patients to law enforcement.
  • Understand that the care for a patient after self-managed abortion is the same as care for any patient with bleeding in early pregnancy.
  • Identify the components of a differential diagnosis in a patient who reports bleeding in early pregnancy.

When Abortion is Not Available: Caring for Patients After Self-management of Abortion

Presented by Biftu Mengesha, MD, MAS (she/her)

Supplemental Video Content

Early Pregnancy Loss: Diagnosis and Evaluation

Early Pregnancy Loss: At-home-management

Early Pregnancy Loss: Medication Management

Medication Abortion

Resources

 If/When/How

Self-Managed Abortion- What Healthcare Workers Need to Know. Bixby Center for Global Reproductive Health, Advancing New Standards in Reproductive Health

Perspectives on self-managed abortion among providers in hospitals along the Texas–Mexico border

Citations

  1. Conti J, Cahill EP. Self-managed abortion. Curr Opin Obstet Gynecol. 2019 Dec;31(6):435-440.
  2. If When How Lawyering for Reproductive Justice. “Self-Managed Abortion, the Law, and COVID-19 Fact Sheet.” https://www.ifwhenhow.org/wp-content/uploads/2020/04/20_04_Final_SMA_TheLaw_COVID-19_FactSheet_PDF.pdf
  3. Center for Reproductive Rights. “Medical Abortion and Self-Managed Abortion: Frequently Asked Questions on Health and Human Rights.” Dec 2020. https://reproductiverights.org/document/medical-abortion-self-managed-abortion-faq
  4. Donovan MK. Self-Managed Medication Abortion: Expanding the Available Options for US Abortion Care. Guttmacher Institute. Volume 21. Oct 2018.
  5. Rowan A. Prosecuting Women for Self-Inducing Abortion: Counterproductive and Lacking Compassion. Guttmacher Institute. Volume 18, Issue 3. Sept 2015.

Reflection Questions

  • What changes can you make in your practice to destigmatize self-managed abortion and provide patient-centered care?
  • Clinicians are under no obligation to report patients to law enforcement, yet we know actual practice may differ. Have you witnessed the impact of a colleague reporting patients to law enforcement? How did it make you feel to witness that?

Course Development

Abortion is a common experience and happens at similar rates in most communities, regardless of the legal restrictions in place. This video series contextualizes the ethical and clinical considerations for clinicians and learners living in states or communities where abortion is highly restricted or inaccessible. 

This curriculum, curated by Dr. Jody Steinauer, MD, PhD, was created in collaboration with 4 experts on abortion from a range of professions and disciplines: 

  • Ana Delgado, CNM, MS, a midwife, abortion provider, educator, and community activist.
  • Teresa DePiñeres, MD, MPH, a Board Certified ObGyn, specialized in Complex Family Planning and Abortion.  She is an independent contractor in international sexual and reproductive health, as well as a mentor and coach.
  • Bhavik Kumar, MD MPH, a family medicine physician providing abortion care, gender care, and primary care in Houston, Texas. 
  • Biftu Mengesha, MD, MAS, a Ob-Gyn physician and abortion provider and Director of Innovating Education in Reproductive Health.