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Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills. Geneva: World Health Organization; 2013.

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Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills.

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9POST-ABORTION CARE

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What is in this session?

This session focuses on the specific counselling needs of women who have experienced an abortion. This includes women who have experienced a miscarriage as well as women who have had an induced abortion.

What skills will I develop?

  • Forming an alliance: Building a relationship with the woman
  • Active listening
  • Self-refection
  • Empathy and respect
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What am I going to learn?

By the end of this session you should be able to:

  1. Reflect on your own beliefs, attitudes and values.
  2. Understand the key components needed to develop a relationship with the woman.
  3. Demonstrate active listening skills.
  4. Understand the key local resources in your area to support women.

What is miscarriage and abortion?

The term abortion refers to the termination of a pregnancy. Spontaneous abortion or miscarriage is an unintended pregnancy termination. Induced (elective) abortion is an intentional pregnancy termination by surgical, medical or other means.The emotional needs of a woman who has had an induced abortion may differ from the needs of a woman who has experienced a spontaneous abortion. However, in both circumstances, a wide range of emotions are common. Some women may feel upset, anxious or sad. In the case of a spontaneous abortion a woman may worry that something she did caused the pregnancy loss. Some women feel relieved after an abortion.

Your skill as a counsellor will be to support a woman in working through all the feelings and emotions she may be experiencing (regardless of whether the abortion was induced or spontaneous), to help her to deal with these emotions and with any practical issues such as how to tell other people, as well as to support her in planning for the care she needs to take of herself thereafter.

What is post-abortion care?

The WHO PCPNC outlines the key clinical examinations, treatment and care that should be provided to a woman who has experienced bleeding in early pregnancy or an abortion. If you do not have access to the PCPNC, use the national guidelines for the management of post-abortion care. In this session the focus is on developing your skills to improve counselling with women who have experienced an abortion, and to respond to the information needs of these women.

KEY ISSUES TO COVER WITH THE WOMAN AFTER AN ABORTION

WHO recommends the following advice be reviewed with a woman after an abortion:

SELF-CARE

  • Some women prefer to rest for a few days, especially if they feel tired.
  • It is normal for women to experience some vaginal bleeding (light, menstrual-like bleeding or spotting) for several weeks after an abortion.
  • Some pain is normal after an abortion, as the uterus is contracting. A mild painkiller may help relieve cramping pain. If the pain increases over time, the woman should seek help.
  • Change pads every 4 to 6 hours. Wash pad or dispose of it safely. Wash perineum.
  • Do not have sexual intercourse or put anything into the vagina until bleeding stops.
  • Practice safe sex and use a condom correctly in every act of sexual intercourse if at risk of STI or HIV.
  • Return to the health worker as indicated.

FAMILY PLANNING (See Session 12)

  • A woman can become pregnant as soon as she has sexual relations. Use a family planning method to prevent an unwanted pregnancy and a condom to prevent infection with STIs/HIV/AIDS.
  • Assuming there are no complications from the abortion, almost any contraceptive method can be started immediately
  • Talk to the health worker about choosing a family planning method which best meets you and your partner's needs.
  • After a spontaneous or induced abortion, the recommended interval to the next pregnancy is at least six months, both for the mother's and the baby's health.

DANGER SIGNS

If she has any of these signs she needs to go to the health centre immediately, day or night. DO NOT wait:

  • Increased bleeding or continued bleeding for 2 days
  • Fever, feeling ill
  • Dizziness or fainting
  • Abdominal pain
  • Backache
  • Nausea or vomiting
  • Foul-smelling vaginal discharge.

In addition to these points, women may need to discuss with you issues related to resuming sexual relations. Some women may not want to have sexual intercourse for some time afterwards. This may continue even after she has physically recovered. These feelings may be complex and represent fear of getting pregnant again, or grief or guilt related to a spontaneous or induced abortion. The counsellor should try to provide support around this issue, starting with acknowledging to the woman that this is a well-known effect after an abortion.

Activity 1

Image session9fu3.jpg1 to 1 ½ hours

Image session9fu4.jpgTo reflect on your own beliefs and attitudes with respect to spontaneous and induced abortion.

Before beginning this session, it is important to first explore your own beliefs and attitudes about spontaneous and induced abortion and towards a woman who has had an abortion, as these can affect the support you provide her.

This activity should be done in a group. If you are working on your own, ask some colleagues or friends to help you with this activity. Be prepared for some intense discussion, as abortion is a topic about which many people hold strong opinions and which may be influenced by religious values and other social norms.

Note to facilitator: if you have a group where everyone agrees with each other and you are worried that certain beliefs or attitudes are being reinforced by the group, divide the group into two smaller groups. Ask one group to agree with the statement and supply their reasons, and the other group to disagree with the statement, also giving reasons. By exploring/debating opposing views the participants will gain a deeper insight into different perspectives, thus helping to generate a meaningful and thought-provoking discussion.

  1. Discuss the following statements. Make sure everyone participates. Encourage differences of opinion but protect each person's right to express her/his attitudes, values and beliefs. You may find it useful to set some ground rules for the discussion such as: do not interrupt one another, do not personalize information, and do not raise your voice. Remind the group that there are no “right” answers.
    • “A woman has the right to choose whether to terminate her pregnancy.”
    • “If a woman deliberately induces abortion she is committing murder.”
    • Women "cause" their own miscarriages.
    • “Some women want to terminate a pregnancy as they are too poor to feed another child.”
    • “Women should feel guilty if they have had an abortion.”
    • “Women who deliberately induce abortion do not deserve the same level of care as women who experience spontaneous abortion.”
    • “Choosing to terminate a pregnancy is a hard decision to make and women need support and encouragement to carry out their decision.”
  2. Did everyone in the group have the same attitudes, values and beliefs?
  3. Which statement caused the most disagreement?
  4. How did people feel if their beliefs, values or attitudes were different from the majority of the group?
  5. How might some of these attitudes, values and beliefs regarding spontaneous and induced abortion be expressed directly or indirectly to women?
  6. How do you think this might make them feel?
  7. Think about your own responses - do you feel you have any negative attitudes towards women who have had an abortion? What kind of support would you need to overcome these negative attitudes? Do you feel or act differently towards women who have had a spontaneous abortion or an induced abortion? Why do you think this is?

Image session9fu5.jpgOur View

We all have different views about these statements. Holding a belief, value or attitude different from the majority of the group can make you feel insecure or defensive. This will help you to understand what it feels like in a situation where a woman knows that health workers disagree or disapprove of her. Be aware that if you have very strong attitudes and beliefs about abortion, you might communicate them indirectly through your body language, tone or the courtesy and respect you show or even more directly to the woman by telling her how you feel.

The health worker's role is to support women to make decisions to take better care of themselves. In order to do this, you need to discuss with women and this discussion can only happen by treating all women with respect, including respect for their beliefs. Try to overcome your own negative attitudes and beliefs and provide care and information in a neutral and non-judgemental manner in order not to impair your counselling relationship. If you feel unable to overcome your beliefs or attitudes, then you should ask a colleague to take over from you.

How to provide information and support after an abortion

Women undergoing an abortion should receive clear, simple oral and written information about how to care for themselves after leaving the health facility and how to recognise danger signs that require attention. In addition, information and counselling should be provided on contraception. Women may experience a range of different emotions after an abortion. The health worker can provide needed support to them during this difficult time. Below we have outlined some different skills you will need to do so, including:

Building an alliance with the woman

The counsellor's first task is to build an alliance, or a partnership, with the woman. This alliance serves as the foundation that encourages the woman to engage in the session. Building a relationship is especially important after the trauma of an abortion. The important skills in building relationships include showing empathy, overcoming beliefs, values and attitudes and active listening.

Ability to empathize with the person you are counselling

Empathy means understanding the woman's situation from her perspective and trying to focus on her feelings. To empathize is to put yourself in the woman's shoes and to try to see the situation as she sees and feels it, taking into account the impact her family, education, culture and life circumstances will have on these feelings. This can be a difficult thing to do, especially if we disapprove of the actions someone has taken because of our own beliefs, values, and attitudes.

Ability to overcome beliefs, values and attitudes

Sometimes health workers do not want to provide services if they believe that the person has carried out an action with which they disagree. They can also treat a woman rudely if they feel she is suffering because of her own lack of knowledge or incorrect behaviour. This is particularly true in the case of an induced abortion about which many people have strong beliefs and attitudes. Can you think of examples of this where you work?

We all have values and beliefs and it is important not to impose these on others. Our values will have come from our experiences and will change at different points in our lives. Within any community it is unlikely that everyone will hold exactly the same attitudes, values and beliefs because they are shaped by many factors related to individual experiences. While each person is entitled to her/his own beliefs and attitudes, health workers have a professional obligation not to allow these to become a barrier to providing care. It is important to take a look at yourself and to be aware of how your own beliefs, values and attitudes influence how you interact with any individual woman, or influence what you say and do.

Active Listening

Active listening is another step that you need to practise to build a relationship. Active listening is about demonstrating that you are listening carefully. You can do this through gestures, sounds and body language. You can repeat back what has been said to you. Other methods of active listening include using questions which reflect that you have heard what the woman is saying. Refer back to Session 3 for more details on active listening before you carry out the next activity.

Take time to clarify with your colleagues your different beliefs, attitudes and values to abortion and how these might affect your counselling.

Take time to clarify with your colleagues your different beliefs, attitudes and values to abortion and how these might affect your counselling

Activity 2

Image session9fu3.jpg40 minutes

Image session9fu4.jpgTo help you improve your ability to show empathy and respect, manage your own attitudes, beliefs and values, and practise your active listening skills. This activity will build on the active listening activity in Session 3.

If you are working alone you will need to find some other people to help you with this activity. If you are working in a group, organize yourselves into groups of three – a counsellor, a woman and an observer.

  1. The person playing the woman should take five minutes to make up a role-play focused on the following example: A woman comes to a health facility with sepsis following an induced abortion in the community which has gone wrong. Write down some notes to help you remember your story.
  2. The counsellor and woman should carry out the role-play with the observer watching. If you are to play the counsellor try to show active listening through the use of body language, gestures, sounds and repeating back what has been said to you. Try to demonstrate empathy by expressions of understanding, including clarifying to her what you understand the woman is feeling, in terms of her worries, concerns, emotions and needs. You also need to be aware of your own values, attitudes and beliefs and how these may affect your counselling and interactions with her.
  3. As the observer try to look for two or three examples of things that the counsellor did which demonstrated active listening and empathy appropriately. Comment on any aspects the counsellor could improve. Could you tell what the counsellor's attitudes, values and beliefs were? Use the checklist below to help you provide honest and accurate feedback to the person acting as the counsellor.
  4. Ask the person playing the woman how she felt during the interaction. Did she feel at ease to speak her mind? Did she feel that the counsellor understood her feelings? Her situation? Her problems? What were the good things the counsellor did that helped her to feel supported? What were things that could have been improved?
  5. Switch roles so that everyone has the chance to play each of the different roles.

OBSERVER'S CHECKLIST

Counsellor:

  • maintains good eye contact (where culturally appropriate)
  • nods and smiles at appropriate times
  • demonstrates open body language
  • demonstrates empathy and respect through understanding/caring language
  • does not give direct advice but helps woman to explore her options
  • does not sound harsh or judgemental despite own beliefs and values
  • paraphrases questions back to show understanding
  • asks clarifying questions when the woman does not understand what is being said
  • allows an opportunity for the woman to ask questions.

Image session9fu5.jpgOur View

You were probably very aware of being observed and it may have been difficult to concentrate on active listening, showing empathy and being aware of your own feelings, attitudes, values and beliefs. As you practise these skills when counselling women you will hopefully find that they become easier to carry out. Use your notebook to reflect on your skills following counselling sessions, until you feel more confident that you are able to put into practice these different skills.

Evaluating needs for further support

Many women will need continued support following an abortion whether it is induced or spontaneous. As you talk to the woman, her story may suggest other social or health concerns, such as concerns about infertility, violence in the home or isolation. Find out from the woman if she is interested in getting additional support and from whom she prefers that support. You can help the woman identify someone she would like to talk to who could listen and help to share her feelings and emotions.

She might prefer anonymous support in the form of a counsellor or specialized counsellor if she has a particular problem such as violence in the home (refer to Session 16) or infertility issues. Remember she has a right to maintain privacy.

Depending on the circumstances surrounding the abortion or miscarriage, she may or may not wish to involve others such as her partner or family members. If she wants her family involved, together you might be able to work out some emotional and practical ways that they can support her and also talk to them about post-abortion complications so that they are aware of what to do and what signs to look out for.

There may be other support mechanisms available in the community, or you may know of other women who have experienced an abortion and who would be available for support. You and others in the health centre should be aware of these possibilities and have the information available for those women who need it.

In addition, it may be appropriate to refer a woman to other sexual and reproductive health services, such as HIV/STI screening, cervical cancer screening or other preventative health measures.

Activity 3

Image session9fu3.jpgvariable

Image session9fu4.jpgTo develop a list of sources of support for women who have experienced an induced or spontaneous abortion. This activity links up with work you will be doing in Session 17.

  1. Talk to colleagues, other health care providers, volunteer organizations, NGOs, religious and support groups to make a list of organizations that provide support to women following both spontaneous and induced abortion.
  2. Once you have made this list, make it available for staff in your workplace. Also consider making it into a leaflet to give to women who have had an abortion. You could also combine it with the information on danger signs following abortion.

Image session9fu5.jpgOur View

This list of sources of support will be a useful tool for your staff in communication and counselling. The list could be used as an aid to discussion and to facilitate counselling as well as providing important information to women.

What did I learn?

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You have reviewed your attitudes towards women who have experienced an abortion and you should know if these present a barrier to how you provide them with care. You have examined how to provide care and counselling in a non-judgemental way. You know the importance of establishing a professional relationship with women, encouraging them to actively engage in the session. You have practised your active listening skills and how to show empathy and respect. You also made a list of additional support available for women following an abortion.

When counselling a woman after an emotional experience such as an abortion, you may feel emotionally drained yourself. It is important to maintain an awareness of how you are feeling and your own emotional state. Take some time now to reflect on what you can do to take care of your own emotional needs. Write these things down in your notebook. They might include activities such as talking through sessions with a colleague, friend or your mentor (remembering to maintain confidentiality). They might involve doing something for yourself like spending some time with your family, or taking a walk or any activity which you find relaxing. Learn to recognize signs of stress in yourself and develop practical ways to relieve it.

Copyright © World Health Organization 2013.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep).

Bookshelf ID: NBK304195

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