Gender and Policy Network

 

In many countries around the world, abortion is illegal and is a cultural taboo. A woman desperate to terminate a pregnancy will often turn to an unlicensed provider who performs abortions in unsanitary conditions. Unsafe abortions frequently result in medical complications, and so a woman must go to the closest emergency room—even if that means walking miles to get there.

 

When she reaches the hospital, she can expect to be mistreated and disrespected, since she is regarded as a deviant and criminal. Providers commonly withhold her medication for pain control, threaten to report her abortion to the police and to her family, and delay her treatment as a punishment for her crime. Although this woman may not know how to prevent an unwanted pregnancy in the future, she will typically be discharged from the hospital without ever being told about her contraceptive options.

 

 

I spent four years, 1998-2002, working to improve women’s health services in developing countries. I specialized in developing counseling training programs for providers assisting women with complications caused by induced abortion and miscarriage. My job was to assess how counseling training could yield a more comprehensive and more compassionate quality of care, and to develop and test a curriculum for this purpose.

 

During my travels, I spent much of my time in the emergency rooms of hospitals in Asia, Africa, and Latin America. I interviewed patients, doctors, and nurses about what leads women to terminate pregnancies, and we discussed how counseling can help these women access better curative and preventive care. I observed staff performing clinical procedures and demonstrated how to use touch and words as a form of pain management. I led training workshops for doctors and nurses on how to integrate counseling into all their interactions with patients, and how to give empathetic care in spite of one’s own personal feelings about women who induce abortions.

 

Our interviews with patients revealed that many postabortion women at the hospital hadn’t been informed about what treatment they would receive for their condition. Furthermore, many patients were very anxious about their health condition and needed their fears calmed before they could engage in discussions about prevention of future unwanted pregnancies. To address these issues, the curriculum we developed focused on how providers could best respond to patients experiencing anxiety or fear, and we emphasized the need to keep women informed of what to expect during and after their treatment procedures.

 

 

During interviews with providers we learned that many doctors and nurses feel that they don’t have sufficient time to counsel postabortion patients. Many providers understood the principles and rationale behind counseling, but they perceived it as a service that must take place in a private room, with a long period of time dedicated to discussing each patient’s concerns. Because we were focusing on emergency room settings, we had to modify the “ideal” counseling model to fit the providers’ working reality. In our training we emphasized how to integrate counseling into each interaction with a patient. This included simple measures such as addressing the patient by name, asking her how she was feeling, and asking her if she had any questions.

 

In response to these needs, we developed an interactive training workshop designed specifically for doctors and nurses (rather than professional counselors). The curriculum focused first on attitudes and values; then on basic communication skills; and finally on postabortion counseling before, during, and after the treatment procedure. To make the content locally and culturally appropriate, providers developed their own profiles of hypothetical patients, representative of the postabortion women they treat. These case studies were used as a real-world reference point throughout the workshop, to ground the exercises in a tangible application. The trainings concluded with a clinical practicum, in which providers tried out their new counseling skills on actual postabortion patients.

 

 

People often ask me whether I think my work “made a difference.” Measuring the impact of counseling training is challenging, because its central objective is for providers to assess their own attitudes and values, and then change their behavior. With such ambitious intentions, you must set reasonable expectations of what indicates success. I made it my goal to foster empathy in at least one person I met in each trip. It only takes one person to set an example, build momentum for social change, and then change lives.

 

A Kenyan nurse that I trained in counseling demonstrated how the workshop had changed her relationships with patients. During the clinical practicum, she counseled a young woman on topics ranging from reproductive health to basic nutrition. The nurse was so affected by the counseling experience that she made a special visit to the hospital on her day off, just to check up on the patient. Other providers have experienced a similar shift in how they view their interactions with patients after counseling training. One Ugandan doctor told me that it had never occurred to him to engage in this sort of dialogue with patients, and he found it incredibly valuable to learn about patients’ wants and needs.

 

These providers learned first-hand how counseling could enhance both their own work and their patients’ lives. My hope is that they will show and tell what they have learned, and that colleagues and students and supervisors may follow this model. This change among individuals can build in momentum and yield higher standards of compassionate, quality care among more than just a few individuals. This is the change that makes a difference in the world.