CONTENTS
HIGHLIGHTS
September, 1997 |
Counseling is an integral component of postabortion family planning services. Every woman treated for abortion complications needs and deserves family planning counseling. Family planning programs have repeatedly found that women are more likely to begin using a family planning method and to use it effectively when they are adequately and effectively counseled than when they do not receive counseling (79). Although evaluations specifically of the effects of postabortion family planning counseling have begun only recently, they suggest that counseling is as important for women recovering from abortion complications as for other family planning clients—and often more important (90, 92, 246). Also, when a woman has had an unintended pregnancy because she did not understand how to use her method or stopped using a method that had unacceptable side effects, the counselor can help the woman correct her method use or switch methods. Family planning counseling can be the crucial step for a woman in deciding to use a family planning method, learning to use it correctly, and continuing to use it (42, 79). For example, among Egyptian women treated for abortion complications, when counseling was increased, intent to begin using family planning also increased (103). Among Nigerian women treated in four hospitals for incomplete abortion, 39% of those counseled about family planning began using a method, while only 8% of women not counseled did so (64). Also, providing counseling after postabortion care was associated with a significant overall reduction in the risk of repeat unintended pregnancy, according to a study that looked at data from Kenya, Mexico, Nigeria, Zambia, and Zimbabwe (180). What is good counseling? Good counseling is a discussion between provider and client that helps each woman apply family planning information to her own circumstances, make her own decisions based upon her specific needs and wants, and act on these decisions (79). By listening to a woman and paying attention to her needs, a counselor can help her make a considered, informed decision about family planning (143, 200, 202). No single approach to counseling suits all situations or meets all women's needs (278). Postabortion family planning counseling that is flexible and treats women as individuals is most likely to meet women's needs (161). Effective family planning counseling relies on interpersonal skills—chiefly active listening and attending behavior (18, 79, 276). Active listening means acknowledging what the woman has said; paraphrasing and summarizing her statements; reflecting back her feelings with summary statements or questions; encouraging her to speak and to ask questions; and responding directly and honestly to her questions and to the information she provides about her personal situation. Attending behavior means using nonverbal cues that show that the counselor is paying close attention: leaning forward and facing the client, establishing eye contact, smiling, and sitting squarely, for example. Such nonverbal cues help establish rapport and trust between the counselor and the woman (79, 144, 163, 276). An effective counselor avoids pressuring a woman to choose a particular method but, instead, guides her in evaluating which methods best meet her own needs. Achieving a balance between listening and giving advice can be challenging. Service providers who have been trained to tell patients what they need to do from a medical standpoint often find it difficult to emphasize choice because they know much more than their clients know about contraception. For example, a study observing service providers in India found that doctors urged postabortion women to use IUDs or voluntary surgical sterilization, without considering the woman's own needs or her reproductive goals (200). Conversely, a study in Kenya found that many family planning counselors were offering too little guidance to women in evaluating medical information and applying it to the women's personal situation because counselors wanted to avoid pressuring the women (143). Training counselors. Training improves counseling. Trained counselors ask women more questions about themselves, listen better to their answers (246), and give them more information (104). Training is especially important to effective postabortion family planning counseling because postabortion care often takes place as part of a medical and emotional crisis. Counselors usually must help postabortion women address a broader range of issues than other family planning clients need to address, including immediate health concerns as well as possible future psychological suffering and social consequences (141). In Egypt, for example, women and their partners wanted reassurance about the woman's immediate health condition before they were interested in family planning information or counseling (1). Even experienced counselors can benefit from additional training in postabortion family planning counseling. Family planning counselors—like all providers working with women who have undergone unsafe abortion—need training that prepares them to address the emotional aspects of unsafe or spontaneous abortion, including their own and others' attitudes toward abortion (see sidebar Put Yourself In her Shoes). Many counselors and providers need to learn to put aside their biases so that they can empathize with women and counsel them compassionately. Training can also prepare counselors to work with others who have punitive attitudes toward women treated for abortion complications. Often, a family planning counselor is the only person available to serve as a woman's advocate with other providers to ensure that she receives good medical care. Because postabortion counseling can be emotionally demanding and draining, counselors need a support system to help them avoid emotional burnout themselves. As well as counselors themselves, other staff members—including nurses, midwives, physicians, social workers, nurse aides, and other family planning service providers—can learn how to provide counseling. One or two members of the staff can be trained to specialize in family planning counseling, or the entire staff can share the responsibility. Volunteers also can be trained to offer women basic family planning information (276). All medical staff members who interact with clients during emergency care need training that helps them to provide women with nonjudgmental care (246). Using GATHER in postabortion counseling. The GATHER approach to counseling (163), already familiar to many family planning providers, can guide postabortion counseling as well. The sidebar, The GATHER Approach to Postabortion Family Planning Counseling, emphasizes aspects of postabortion family planning counseling that differ from other family planning counseling. These differences include:
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