ATT D13 Clinical Guidance Pregnancy Options Counseling.pdf

Patient-Centered Pregnancy Options Counseling

The Department of Veterans Affairs (VA) has amended its regulations to remove the exclusion on abortion counseling from the medical benefits package. Abortion counseling is now included as a component of pregnancy options counseling provided by VA staff and clinicians.

Pregnancy options counseling means discussing the pregnant person’s options in relation to their health and wellbeing. Options include:

• to continue pregnancy

• to have an abortion

Pregnancy options counseling is available to all Veterans who receive care under the Medical Benefits Package when clinically appropriate as part of reproductive health care, regardless of whether VA could provide them with an abortion.

Pregnancy options counseling is generally taught as part of clinical training for health care professionals across disciplines, including, but not limited to, family medicine, internal medicine, emergency medicine, obstetrics and gynecology, nursing, and social work, mental health, etc. Preconception care and early pregnancy management are standard components of the comprehensive care of Veterans. In addition to pregnancy options counseling provided by physicians and advanced practice providers, pregnancy options counseling appropriate to scope can be provided by nurses and social workers who already provide education and counseling to patients similar to the way nurses and social workers might engage with patients about nutrition or anticipatory guidance for other outpatient procedures.

The goal of patient-centered pregnancy options counseling is to provide individualized counseling to aid the pregnant person in understanding and exploring all possible pregnancy options so the individual can make an informed and voluntary decision for their health and wellbeing that is consistent with their values and treatment preferences.

Providers should be knowledgeable about the different pregnancy options, relevant terms, and be skilled in unbiased and effective patient-centered counseling techniques.

Providers should be aware or else have access to other service lines such as social work, who can provide the patient with a complete and comprehensive list of services available outside of the VA health care system related to various medical, support, and other services relevant to pregnant Veterans. The list should be updated periodically and make clear that VA makes no recommendation for, or endorsement of, any of the entities on the list. This should be provided if a requested medical service is not available within the VA health care system, the patient prefers to receive their pregnancy-related care outside the VA health care system, or the patient simply seeks to know what pregnancy-related care and support options exist outside of the VA

Office of Women’s Health Last Updated March 1, 2023 healthcare system. The patient is to be free to select from the list any entity or provider they prefer and seek care there.

NOTE: Clinicians should recognize and respect patients’ preferences and ensure that those preferences guide all VA treatment decisions. A VA clinician must ensure all pregnant Veterans and VA beneficiaries have information about all their VA health care and other benefits. For some VA clinicians, this may require them to ensure that their personal values do not interfere with their professional role. In the event a VA clinician is unable to provide pregnancy counseling, the facility must ensure a warm hand-off to another VA provider who agrees to accept the case and provide the counseling to the patient in a timely manner. (Facilities would benefit from having updated schedules that identify those providers who are able to provide the needed counseling during operational hours and their respective schedules.) The warm hand-off should be documented in the patient’s medical record, to include the accepting provider’s response and the scheduling of the counseling appointment. It is underscored that

Veterans are eligible for this type of counseling and so facilities have the responsibility to ensure adequate coverage exists during open hours and that it can schedule these internally transferred counseling sessions on an expedited and urgent basis. To avoid the perception of patient abandonment, both the transferring and accepting VA providers must timely document this process and the ultimate provision of counseling.

Quality counseling principles include the following elements:

• Establish and maintain rapport with the pregnant person in an open and non-judgmental manner.

• Assess the pregnant person’s medical needs and treatment preferences and individualize discussions accordingly.

• Provide comprehensive medically appropriate information that can be understood by the pregnant person in a manner consistent with informed consent principles.

• Confirm the pregnant person’s receipt of information and understanding of information on all resources available outside the VA health care system.

• Answer all patient questions.

• Establish a VA treatment plan collaboratively with the pregnant person for those services available within VA.

Best Practices in Pregnancy Options Counseling:

1. Do not expect a positive pregnancy test to be the pregnant person’s desired result. Maintain neutrality, meaning that you understand that the person’s reaction could be positive, negative, or ambivalent and avoid judgment.

a. “Your pregnancy test is positive. Not everyone has the same reaction to that result. How do you feel about this?”

2. If the pregnant person is unsure of their plans, begin to explore all available options together.

a. “You have several options with this pregnancy. Would you like to explore those with me?”

b. See “Options” further outlined below

3. If the pregnant person reaches a decision, connect them to the appropriate resources.

a. “Okay, it sounds like this is the way you’d like to proceed today. Let me help explain the next steps.”

4. If the pregnant person is undecided, identify social supports and discuss a timetable relevant to their presumed gestational age.

a. “I can imagine this is a lot to absorb. It’s reasonable to take some time to process if you need to. These are additional resources you can review. If you come to a decision and you’d like us to help coordinate your care, contact your PACT right away.”

5. Always ensure the pregnant person has appropriate contact information for any additional questions and/or to enact a plan.

6. Always leave room for a pregnant person to change their mind now or in the future.

7. Always maintain empathy.

8. Normalize all patient reactions.

9. Attend to verbal and non-verbal cues and individualize care.

Pregnancy options include:

1. Continue the pregnancy

a. Maternity care is covered under the VA medical benefits package.

b. Parenting

i. The Veterans Health Library offers parenting resources. Additional resources for parenting may be available through social work services.

c. Adoption

i. Adoption information may be available through social work services. VA does not provide adoption services.

2. Abortion

a. VA’s medical benefits package excludes abortions except when: 1) the life or health of the pregnant Veteran would be endangered if the pregnancy were carried to term; or 2) the pregnancy is the result of an act of rape or incest. Care in the medical benefits package will be provided to individuals only if it is determined by appropriate health care professionals that the care is needed to promote, preserve, or restore the health of the individual and is in accord with generally accepted standards of medical practice.

(i) Promote health. Care is deemed to promote health if the care will enhance the quality of life or daily functional level of the veteran, identify a predisposition for development of a condition or early onset of disease https://www.womenshealth.va.gov/topics/maternity-care.asp which can be partly or totally ameliorated by monitoring or early diagnosis and treatment, and prevent future disease.

(ii) Preserve health. Care is deemed to preserve health if the care will maintain the current quality of life or daily functional level of the veteran, prevent the progression of disease, cure disease, or extend life span.

(iii) Restore health. Care is deemed to restore health if the care will restore the quality of life or daily functional level that has been lost due to illness or injury.

b. The decision about whether continuing the pregnancy endangers the person’s health (to include mental health) or life is made on a case-by-case basis by the patients’ provider(s) after discussion between the patient and their provider. Each situation is different. In some situations, it may be helpful to consult with another provider, such as maternal-fetal medicine, mental health, neurology, etc. However, access to abortions is time-sensitive and request for additional input must be balanced against delaying care.

c. In cases of rape or incest, self-reporting from a Veteran or CHAMPVA beneficiary will constitute sufficient evidence that an act of rape or incest occurred, meaning that the exclusion of abortions in the medical benefits package would not apply in this situation

d. Veterans who do not meet these criteria but who are interested in obtaining an abortion may seek care outside of the VA healthcare system.

CHAMPVA beneficiaries who do not meet these criteria but who are interested in obtaining an abortion may seek care, but it would not be covered by CHAMPVA. Resources regarding clinics/clinicians outside the

VA health care system who provide abortion should be offered.

e. Medication Abortion is generally available through 70 days (10 weeks) estimated gestational age.

f. Abortion procedures are safe through 24 weeks gestation, but this timeline may be different based on individual patient characteristics, provider recommendations, and availability.

g. Induction abortion may be offered in the 2nd trimester based on provider recommendations and availability.

Medical terminology to use in counseling:

Avoid Try Instead

“baby” “pregnancy”, “fetus”

“womb” “uterus”

“Putting the child up for adoption” or “give up the baby”

“Make an adoption plan”, “choose to consider adoption”

“Keeping the baby” “continuing the pregnancy”, “choose to be a parent”, “Termination” “Abortion”

“Elective abortion” “Abortion”

“Abortion provider” “Clinician who provides abortion”

“Chemical abortion” “Medication abortion”

“Surgical abortion” “Abortion procedure”

Resources:

1. ABORTION ACOG – Abortion: Resources Overview http://www.acog.org/Womens-Health/Abortion

2. Exploring All Options: Pregnancy Counseling Without Bias Video | Reproductive

Health National Training Center (rhntc.org)

3. Pregnancy Options - Bedsider

4. Reproductive Health Access Project | Options Counseling - Reproductive Health

Access Project (reproductiveaccess.org)

5. Patient-Centered Options Counseling Videos – RHEDI http://www.acog.org/Womens-Health/Abortion https://rhntc.org/resources/exploring-all-options-pregnancy-counseling-without-bias-video https://rhntc.org/resources/exploring-all-options-pregnancy-counseling-without-bias-video https://www.reproductiveaccess.org/resource/options-counseling/ https://www.reproductiveaccess.org/resource/options-counseling/ https://rhedi.org/patient-centered-options-counseling-videos/