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ss triple helix - Winter 2019,  Handling abortion requests in general practice

Handling abortion requests in general practice

Hannah Carter looks at a practical, non-directive approach to dealing with crisis and unwanted pregnancy consultations

The aim of this article is to provide a framework for GPs addressing abortion requests. There will be a lot that is left unwritten on this grey topic - such as how gynaecology trainees might deal with the pressure to perform terminations or how we might ever bridge the impasse between the 'pro-choice' and 'pro-life' campaigners with their diametrically opposed agendas.

This article will explore a non-judgmental approach to women presenting to their GP with an unplanned pregnancy (without compromising the doctor's conscience); tools that can help explore the patient's understanding of her options and world view; and highlight the support available in the local community.

Access to terminations in the UK is changing, with women often self-referring directly to the abortion provider, removing the GP from the process. However, from my experience, it means that those women who do contact the GP with an unplanned or unwanted pregnancy, are more willing to explore their feelings and options and as Christian GPs, if we are equipped to do so, are in the perfect place to support them.

A biblical perspective

In John 8:2-11, we read about the woman caught in adultery who is brought before Jesus to be condemned. The Pharisees saw the woman as guilty and contemptible. However, instead of condemning her, Jesus showed her compassion, respect and forgiveness. He turned his eyes away from her as he wrote on the ground and judged her accusers with the words 'Let any one of you who is without sin be the first to throw a stone at her' (John 8:7). She was not sinless, but Jesus met her sinfulness and vulnerability with grace - 'Go now and leave your life of sin'. (John 8:11)

So, how can we treat these vulnerable women presenting with unplanned pregnancies with the grace, truth and compassion that Jesus showed this woman?

Not compromising your conscience

While training, I used my rotations in gynaecology to enhance my objective perspective on the termination of pregnancy services (TOP) offered within the NHS. I attended TOP clinics and saw women having early pregnancy scans and being told that they had already miscarried the pregnancy, breaking down in tears. But I also saw a woman being told that she had a multiple pregnancy and deciding to proceed with it, although she had been ready to terminate a singleton pregnancy.

There was so much pain and hurt in this TOP service that I couldn't help but want to find a compassionate response. Mandatory counselling was almost non-existent. So, I trained in crisis pregnancy counselling, initially using these skills as a volunteer at the pregnancy crisis centre I was involved in, and then began using the same tools in the GP consultation room.

Consultation skills

Rather than engaging in the pro-life vs pro-choice debate, I view the discussions that I have as 'pro-woman' - helping this vulnerable individual make the right decision for her. For some, they will proceed with a termination, but others will opt to keep a baby they may have otherwise aborted.

Women may present determined to have a termination, or unsure and willing to discuss their options. In the former group, I have rarely found any way to open up a deeper conversation and tend to signpost them to self-referral for termination and also a crisis centre in case their presentation is a façade for the GP and there might be underlying indecision.

In the latter group, often questions such as, 'Have you spoken to anyone about this pregnancy yet?' enables the conversation to start to explore their thoughts, or 'You've come in today to request an abortion - tell me how you feel about that decision and how you reached it?' The aim is not to coerce a patient or tell her what she's feeling but to get her to talk. As much as possible, leave the space open for the patient to explore her feelings.

One tool that crisis pregnancy counsellors are encouraged to use is the Head-Heart diagram also known as 'The 4H tool'. (1) This involves scribbling two circles on a piece of paper and filling in the influences that might affect a woman's decision to proceed with or terminate a pregnancy. I would encourage you to grab a blank sheet of paper as it draws the attention from a face-to-face consultation to the paper, which can encourage the woman to open up (see above).

Heart influences may include her conscience, beliefs, values, instincts and thoughts towards the pregnancy. These tend to be unchanging despite changes in circumstances and tend to be a good indicator of how the woman is really feeling. Head influences may include work, partner, family and friends, mental and physical health, studies/career, finances and housing. These things may change but at the time can seem like the most overwhelming obstacles to a woman considering her options. (2)

Once these influences are on paper, they can be explored further. Are there benefits or bursaries available to the woman? How does she think her family will respond to news of the pregnancy and why? Another thought-provoking question might be 'If you could change one thing in this situation, what would it be?' It is rarely the pregnancy!

I have found it helpful to be practical - how old is she and what are her future fertility options like? A woman in her mid-thirties may wish to make the most of her opportunity to be a mother.

At the end of these consultations, it's unlikely you will know how the woman will proceed - that decision will take time and, ideally, the support of family and friends. So, you can provide her with the information she requires to self-refer (if this is an option to you locally), with information to access further support and you can book her in for a follow-up appointment.

Local centres

Identify and contact your local crisis pregnancy centre by searching the 'Pregnancy Choices Directory' online. It is likely that these centres may offer phone consultations, so don't be discouraged if there aren't centres for miles. Ensure that you are happy with the service being offered and that you are prepared to signpost your NHS patients in their direction.

On this highly politicised topic, it is important that the services recommended meet with the high standards that the NHS expects. Visit the centre and collect some of their literature to hand to patients. If the service is good, tell your colleagues about it as they can also benefit from the support of these charities. You can also get involved with these centres - most are small charities desperate for support in prayer, finances or time - as a volunteer or trustee.

The crisis centres may offer services beyond counselling which you can utilise. For example, Choices offers befriending services which are able to signpost women to further local community support and advice: a community mums' group, a baby boutique - supplying quality baby equipment and self-esteem workshops.

A further resource is the Pregnancy Centres Network (pregnancycentresnetwork.org.uk), to support the non-directive pregnancy crisis centres with prayer, resources, and encouragement. They have a wealth of resources to help support and signpost women.

For many GPs, a patient presenting with an unplanned or unwanted pregnancy may result in feelings of heart sink, but I have found that these consultations can be the most rewarding. Vulnerable women can explore their personal worldviews and complex thoughts towards their pregnancy and can be met with grace, love and truth; they can be offered a space to think, away from the pressure and coercion around them.

Hannah Carter is a GP in north London and Chair of Trustees for Choices, a centre offering counselling for women facing unplanned pregnancy or those experiencing distress following an abortion. choicesislington.org

References
  1. Houghton M. Pregnancy and abortion: your choice. Malta: Malcolm Down Publishing Ltd, 2017:34-39
  2. Ibid:61-65
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