The Abortion Option

A Values Clarification Guide for Health Care Professionals The National Abortion Federation (NAF) is the professional association of abortion providers in the United States and Canada. We are grateful to Alix Hirabayashi and Lisa Butel who revised, expanded, and updated this publication. We acknowledge Laureen Tews, MPH who provided feedback and guidance, and who developed and wrote with Terry Beresford the 1998 publication on which this guide was based. We additionally acknowledge Annie Baker, Joan Garrity, and Pat Anderson who provided expert feedback on the original 1998 publication and Educational Foundation of America, The Richard and Rhoda Goldman Fund, The John Merck Fund, Open Society Institute, and The David and Lucile Packard Foundation whose generous support of NAF’s Access Initiative Project and programs to educate health care professionals made this work possible.

© 2005 National Abortion Federation 1755 Massachusetts Avenue NW, Suite 600 Washington, DC 20036 202/667-5881 www.prochoice.org THE ABORTION OPTION: A VALUES CLARIFICATION GUIDE FOR HEALTH CARE PROFESSIONALS

Why this publication was developed abortion training is not incorporated into The exercises in this publication are designed many residency programs, most health care to help you examine your beliefs about providers will need to decide for themselves abortion so that you may be better able to how important it is to learn about abortion care for women considering this option. and/or to obtain abortion training. Because one’s beliefs about abortion are linked to one’s thoughts about sexuality, The following exercises are designed to help pregnancy prevention, parenting, and you critically examine the factors that might adoption among other issues, some exercises influence your beliefs about parenting, examine these topics as well. While some adoption, and abortion and, for some, your exercises are geared specifically toward choice to become trained and to provide providers who are making decisions about abortion services. They are also intended to whether or not to obtain abortion training illustrate the possible consequences of your and ultimately to be involved in providing choice to provide or not provide service. It is abortion services to their patients, the for these reasons that the National Abortion majority of exercises are appropriate for the Federation developed this publication. wide range of health care professionals who How to use this publication provide care to women. As a health care provider, your responsibility to assess your The legal and historical overviews in Part I feelings about abortion and providing provide background information about the abortion care is greater than that of people in context in which abortion services are other professions, because your decisions will currently provided and the personal and ultimately determine whether or not women public health implications of restrictions on receive accurate information about their women’s access to abortion. This baseline reproductive health care options, are information can help set the stage for health empowered to make the health care decisions care professionals as they proceed with the that are best for them, and are able to obtain values clarification exercises. high quality, supportive, respectful abortion services if they choose abortion. Further, Many exercises that follow in Part II and Part because information about abortion is not III can be used either individually (Part II) or included as a routine component of most in a group setting (Part III). Ideally, both medical school or nursing curricula, and formats will be used so that you will have an

The Abortion Option: A Values Clarification Guide for Health Care Professionals © 2005 NAF i opportunity for personal reflection, free of Why it is important for health care peer pressure, as well as the benefit of hearing professionals to examine our values other people’s viewpoints and testing your In spite of our efforts at objectivity, we all beliefs against possible challenges from others hold personal values that can influence how in your group. we respond to our clients. Sometimes these values are very clear to us and are easily Further, each of the exercises is designed to articulated. Others exist at a deeper level, so stand on its own and, thus, instructors or that we don’t necessarily recognize the others using this publication, particularly in a influence they have on our behavior and group setting, can choose to use only one or judgments as health care providers. Further, two exercises that suit their particular one’s values may change in response to life objectives. Certainly all the exercises have experiences and your encounters with clients value, but given time constraints and other and colleagues may influence your beliefs considerations, the publication is designed to without your having much of a chance to give flexibility to those who use it. reflect on these changes.

We have arranged the exercises in sections to The exercises presented here are intended to help guide users through the various sources help you clarify for yourself your present of influence that affect one’s values. We have personal values about pregnancy options, also included graphics in the upper corners of abortion, and abortion training, and to help the pages that can serve to orient users to the you think about those values in the context of broad categories addressed by the exercises in professional judgments you may be called this publication. upon to make.

Part I – Historical Overview of Laws, Regulations, and Consequences of Limited Access to Abortion Services...... 1

Legal Issues in the United States and Canada ...... 1 Overview of Abortion Laws and Policies in the U.S...... 1 Overview of Abortion Laws and Polices in Canada ...... 2

Consequences of Limited Access to Abortion Services...... 4 Examples in the U.S. during the 1950’s and 1960’s ...... 4 Examples in the U.S. after Roe v. Wade ...... 5

Part II – Tools for Clarifying Our Values ...... 7

Introduction – Individual Exercises for Values Clarification ...... 7

Section A: The Role of External Influences in the Formation of Our Values...... 7 A.1 – Family and Social Group ...... 7 A.2 – Spiritual Beliefs...... 9 A.3 – Life Stage...... 10

Section B: The Influences of Our Personal Experiences in the Formation Our Values...... 10 B.1 – Sexual Intimacy and Risk-Taking ...... 10 B.2 – Parenting, Adoption, Abortion, and Pregnancy Prevention...... 12

Section C: Self-Evaluation of Our Objectivity When Considering a Woman’s Pregnancy Circumstances and Her Options ...... 16 C.1 – Examining Our Comfort Level with Gestational Age...... 16 C.2 – Examining Our Comfort Level with Circumstances...... 17 of Each Woman’s Abortion Decision C.3 – Individual Cases: Examining Our Potential Biases ...... 18 C.4 – Pregnancy Options Decision Making...... 20 C.5 – Parenting and Adoption: Examining Our Potential Biases ...... 22

Section D: Providing Abortion Care: Professional Values Clarification Exercises...... 24 D.1 – Views about the Role of the Health Care Provider ...... 24 D.2 – Personal Assessment of Professional Obligations...... 24 D.3 – The Decision to Provide Abortion Care: Motivations and Obstacles to Practice ...... 25 D.4 – Overcoming Obstacles to Providing Abortion Care: A Self Evaluation ...... 26

Part III – Additional Instructions for Using Selected Exercises from the Guide in a Group Setting...... 31

Past and Present – Historical Overview of Laws, Regulations, and Consequences

PART I: PAST AND PRESENT – HISTORICAL OVERVIEW OF LAWS, REGULATIONS, AND CONSEQUENCES OF LIMITED ACCESS TO ABORTION SERVICES

Legal Issues in the United States means that the decision whether or not to and Canada have an abortion is left to a woman and Given that your professional judgments, and her physician. perhaps your personal values as well, are influenced in part by legal limits and (b) During the second third of pregnancy regulations that govern the medical (about 14 to 24 weeks), state laws may profession, it is appropriate to give a brief regulate abortion procedures only in order overview of the regulations and laws that to protect the woman’s health. relate to abortion. These overviews are by no means meant to serve as a comprehensive (c) During the later part of pregnancy (after review, but will provide a basis for about 24 weeks), and after the fetus is understanding where the law sets limits on viable, state laws may prohibit abortion the provision of abortion as opposed to where except when it is necessary to preserve the individual practitioners or hospitals might set life or health of the woman. Most states personal or institutional limits. (40 states and the District of Columbia) have passed laws to prohibit post-viability An Overview of Abortion Laws and abortions under most circumstances and, Policies in the United States in practice, there are only a small handful of doctors nationwide who offer this care Abortion laws differ, rather dramatically in to women who need it. some cases, from state to state. However, the Supreme Court has issued some key For some time, the framework of Roe v. Wade decisions, starting with Roe v. Wade in 1973, served as the basis by which the which today serve as the basic foundation for constitutionality of state laws related to state abortion laws. abortion was determined. Subsequent Court decisions, however, particularly Planned In the Roe decision, the Court established that: Parenthood v. Casey in 1992, have established that states can restrict pre-viability abortions, (a) In the first third of a pregnancy (about the even in the first trimester and in ways that are first 13 weeks), state laws and regulations medically unnecessary, as long as such may not interfere with a woman’s right to restrictions do not place an “undue burden” on end a pregnancy through abortion. This women seeking abortion services. Thus, state

laws requiring waiting periods before a woman Medicaid recipients to refuse to cover can have an abortion, mandatory counseling counseling or referral for services, such as which promotes childbearing, reporting abortion, which the HMO objects to on requirements, and parental consent or moral or religious grounds. As a result, even in notification have been implemented in many states with expanded funding, women seeking states. (Note: Some state constitutions have abortions may face obstacles to finding a stronger privacy protection than the federal Medicaid provider that will cover services. constitution and thus in these states some of these restrictions would not be permitted.) Since 1996, anti-choice forces in Congress have maintained a statutory ban on even Additionally, in practice, individual hospitals privately funded abortions at all Department of and practices can and do impose other Defense facilities, including military bases. restrictions, such as gestational limits, These facilities are restricted from performing anesthesia requirements, and so forth, on the most abortions, except in cases of rape, life abortion services they provide. Thus even endangerment, and incest. Further, medical though women in the U.S have a insurance for military personnel and their constitutionally protected right to obtain pre- dependents only covers abortion in cases of life viability abortions, these medical services endangerment. Although members of both the might not, in fact, be available or accessible. House and Senate have repeatedly attempted to remove these restrictions they have been A woman’s access to abortion services in the unable to garner enough support to reverse it. U.S. is influenced in part by her ability to pay for that care, either out-of-pocket or through An Overview Abortion Laws and her private or public health insurance program. Policies in Canada The Hyde Amendment forbids the U.S. (Contributed By Joyce Arthur, Director & Spokesperson, Medicaid program from paying for abortions Pro-Choice Action Network, Vancouver, British Columbia, except in cases of rape or incest, as well as Canada) (April 2004) when a pregnant woman’s life is endangered by Canada first liberalized its strict law against a physical disorder, physical injury, or physical abortion in 1969. The new law allowed illness, including a life-endangering physical abortions to be performed in hospitals with the condition caused by or arising from the approval of a “therapeutic abortion committee.” pregnancy itself. States may use their own funds A woman could get an abortion only if the to pay for abortions not covered by Medicaid. committee decided her life or health was in However, only 23 states offer additional funding. danger. But the law resulted in arbitrary obstacles and unequal access for women. Dr. In addition, Congress permits health Henry Morgentaler, Canada’s pioneer abortion maintenance organizations (HMOs) serving provider and pro-choice activist, fought various

court battles culminating in a 1988 Supreme many provinces flout the law due to an anti- Court decision that threw out the entire choice political bias that dismisses abortion as abortion law as unconstitutional. This ruling an “elective” and abortion clinics as private became known as the Morgentaler decision. businesses operating outside of Canada’s universal healthcare system. The Supreme Court grounded the right to abortion in women’s constitutional right to Clinics became legal only in 1988, but there is “security of the person.” One judge also found not enough volume to support clinics except in that the abortion law violated women’s rights to the largest cities. About two-thirds of abortions “freedom of conscience” and “liberty.” Unlike in in Canada are still performed in public the U.S., women’s equality rights are enshrined hospitals. However, only about 20% of hospitals in Canada’s constitution, so courts have been perform abortions, which forces many women very reluctant to confer any rights on fetuses – to travel long distances from their communities. to do so would interfere with women’s Hospitals often restrict access to abortion established constitutional right to equality. because of arbitrary or anti-choice policies. For Various court rulings since 1988 have denied example, many hospitals impose restrictions fetuses any legal recognition in Canada and no such as quotas, gestational limits, and general abortion restrictions have ever been passed. anesthesia requirements. Most hospitals require physician referrals and many have long waiting Although the Canadian legislature tried to re- periods. A few hospitals require the approval of criminalize abortion in 1990, the bill failed to two doctors, or parental consent for any surgery pass. Today, Canada’s governments, judicial on minors with no exception for abortion. system, and the mainstream media are largely Anti-choice doctors and hospital employees pro-choice. often act as gatekeepers, preventing women from accessing abortion services or even Abortion is fully funded by Medicare in obtaining accurate information about them. Canada, except for four provinces that refuse Finally, the Canadian Medical Association to fully fund abortions in private clinics, even maintains an old policy that essentially curtails though they have been ordered to do so under abortions after 20 weeks, unless they’re for a federal law, the Canada Health Act. This compelling health or genetic reasons. law says that provinces must provide all Canadians with equal access to fully funded Anti-choice protest activity is low in Canada, healthcare according to five basic principles: especially in recent years, although clinic portability, accessibility, comprehensiveness, protests are still routine at some clinics, universality, and public administration. particularly in British Columbia, Ontario, and Abortion is probably the only medically New Brunswick. However, three Canadian required treatment that doesn’t fully measure doctors were shot between 1994 and 1997, up to any of these ideals. That is because with American James Kopp as the leading

suspect. A bomb destroyed a Toronto clinic in Examples in the United States during 1992, and one of the shot doctors was also the 1950’s and 1960’s stabbed by an unknown assailant in 2000. A We have excerpted passages from Carole Joffe’s provincial bubble zone law in British Doctors of Conscience1 describing the experiences Columbia, the Access to Abortion Services of physicians who practiced when abortion was Act, protects two clinics and one hospital illegal in most states. from protesters. Clinics in Alberta and Ontario use court injunctions to keep A doctor who was a resident in a New York City protesters at bay. hospital during the 1960’s describing what he called the “Monday morning abortion line-up”: As stated above, this overview should provide What would happen is that the women would get enough general legal information for their paychecks on Friday, Friday night they completing the exercises in this publication, would go to their abortionist and spend their because the exercises focus on personal values money on the abortion. Saturday they would clarification. It is prudent, however, for all start being sick and they would drift in on health care providers in practice to be as Sunday or Sunday evening, either hemorrhaging informed as possible about laws related to the or septic, and they would be lined up outside the medical care that they provide and thus we operating room to be cleaned out Monday would recommend further study of abortion morning. There was a lineup of women on related regulations and legislation in your stretchers outside the operating room, so you state or province. knew if you were an intern or resident, when you came in on Monday morning, that was the first Consequences of Limited Access to thing you were going to do. (Joffe, p.60) Abortion Services The negative impact on public health when Another doctor describing her residency abortion is illegal or otherwise inaccessible is experience with illegal abortion in a county well documented. As a health care provider, hospital: your decision to provide women with There were two gyn wards. They were supposed to unbiased information and appropriate have thirty-two beds each, but they had to have referrals, or your decision to provide or not beds all up and down the hallways. They were provide abortion services has a direct always full [because of illegal abortions]. They influence, positive or negative, on the must have had one hundred and forty beds in those accessibility of abortion. The following wards...The residents would get duties of twenty- examples show possible consequences of four hour periods, and in that period, you’d get ten limited access to legal abortion and may help to twelve admissions. They walked into the you determine what role you might play in emergency room bleeding. The first thing the addressing decreasing access.

1Joffe C. Doctors of Conscience: The Struggle to Provide Abortion Before and After Roe v. Wade. Boston: Beacon Press, 1995

doctor down there did was send them for an X-ray she was not responsive. We finally figured the only to see what was in their belly-to see if there were chance we had was to do a hysterectomy. We took knitting needles, hooks, catheters up their her to the O.R., but Anesthesia said, “We won’t belly...Then when they got to the ward, the first give her anesthesia, without getting blood pressure thing you did besides examine them was to do a or a pulse. We can’t monitor where we are, and so culture for gas gangrene. It was a standard we we might kill her with the anesthesia.” So I had to had, whether they had a fever or not, to take this do something I don’t recommend to anybody, which culture, because if they had gas gangrene, you is a hysterectomy under local anesthesia. We got the really had to take drastic measures, like surgery, uterus out – I still have a picture of it in my heavy duty antibiotics, and all that kind of stuff. teaching files – it was basically a bag of pus. We Until the suction curettage came through, the found a coiled up catheter in there. When we were routine was that you accumulated all the women all done, I was walking along beside her in the until two o’clock in the morning when all the corridor – they were taking her back to her bed. major surgery was done, and the last gunshot And one of the tragedies of this septic shock is that wound had been cleared out of the emergency room people remain lucid until the end, and she was – then the first-year residents dragged the patients holding my hand, and saying, “Doctor, help me, down to the operating room and started doing the I’m dying.” And I knew she was, and I knew there D. & C.’s at two o’clock in the morning. That’s was not a blessed other thing we could do for her, when the operating room was quiet...There would and before she got to her bed, around midnight, she be two or three operating rooms going at the same died, and I have been haunted by that girl ever time. Between 2:00 and 6:00 AM you could get a since. (Joffe, p. 58). certain number of D. & C.’s done and clean up the women who weren’t septic, scrape their uteruses Examples in the United States after and get them back upstairs so they could be Roe v.Wade discharged in a day or two. (Joffe, p. 61) While the scenarios described above occurred before Roe v. Wade, on a smaller scale, similar A chief obstetrical resident in a public hospital situations sometimes still arise because safe, in the 1950’s describing a twenty-two year old legal abortion is still not accessible to many patient whom he treated for septic shock women. A 2003 study2 found that 87% of following an illegal abortion: counties in America do not have a single What happens there, the infection is so abortion provider. Some women, particular overwhelming, the bacteria produce toxins that immigrant women, are unaware that abortion is lead to a collapse of the cardiovascular system. legal in the U.S. and turn to alternative These patients have no blood pressure, no pulse-in methods for self-abortion, for instance self- some cases there is absolutely nothing you can do to administered misoprostol which has been reverse the situation. We gave the girl blood, widely used by women in Latin American cortisone, hydrocortisone – nothing was working, countries for self-abortion and is documented

2Finer LB, Henshaw SA. Abortion incidence and services in the United States in 2000. Perspectives on Sexual and Reproductive Health 2003; 34(1): 6-15.

to be quite widely available in some B) On March 27, 1994, Kawana Ashley, a communities and urban areas in the U.S. nineteen-year-old single mother with a Further, legislative restrictions, such as parental three-year-old son, shot herself in the consent laws, mandatory biased counseling, and stomach during the 25th or 26th week of waiting periods, make it difficult for women, her pregnancy. She was hospitalized but particularly young, low-income, and rural ultimately survived her injuries. Doctors women, to obtain abortions. The following two delivered a female infant by emergency stories are examples of the consequences of caesarean who died 15 days later. Ms. access limited by financial constraints. Ashley was a Medicaid recipient, but since Florida’s Medicaid program funds abortion A) Rosie Jiminez, a 27-year-old woman living only in cases of rape, incest, or life in Texas, died on October 3, 1977 from endangerment, she needed to find a way to complications from an illegal abortion she pay for the surgery herself. Unfortunately, obtained in Mexico. Rosie was on Medicaid by the time she got enough money together, but, because the Hyde Amendment she was into her second trimester, and the prohibits the use of federal Medicaid funds cost was higher. When she had raised the to pay for abortion except in cases of rape, extra money she needed, she was beyond 20 incest, and life endangerment, she could weeks, the cutoff point at which the clinic not obtain a safe legal abortion using her stopped providing abortions. Out of health insurance. While some argued that desperation to end her unwanted pregnancy, Rosie went to Mexico for her abortion Ms. Ashley endangered her own life. because she was ashamed and wanted to protect her privacy, the fact that she had The World Health Organization has estimated twice before obtained a safe, legal abortion that worldwide approximately 80,000 women using her Medicaid coverage, before each year die as a result of illegal or unsafe Medicaid stopped funding abortion abortions.3 Additionally, hundreds of services, clearly connects the cutoff of thousands suffer wide-ranging and serious Medicaid funding with Rosie’s decision to health consequences. Clearly, limited or resort to a cheaper, although illegal, nonexistent access to safe abortion has abortion in Mexico. Rosie was a single monumental consequences for individual mother of a five-year-old daughter. She was women and their families. These figures make a scholarship university student supporting clear, however, the impact on public health herself and her child while in school with when access to safe, legal abortion is restricted. welfare payments and her income from a part-time job. She was six months away from obtaining her bachelor’s degree.

3Unsafe abortion: Global and regional estimates of incidence of a mortality due to unsafe abortion with a listing of available country data. Third edition. Geneva, Switzerland: World Health Organization, 1997. Available at http://www.who.int/reproductive-health/publications/MSM_97_16/MSM_97_16_abstract.en.html

PART II – TOOLS FOR CLARIFYING OUR VALUES

Individual Exercises for Values Section A: The Role of External Influences Clarification in the Formation of Our Values Sometimes it is helpful in the course of External influences on our thinking can narrowing down our focus to look at both the encompass many areas. As we grow up we external and the personal influences on the are introduced to values and ideas by everyone development of our values. Life stage, social around us while we simultaneously compare culture, and our early spiritual environment them to our personal experiences and are examples of external influences on our perceptions. We have chosen to focus on the values. Individual experiences with sexual influence of our culture (family/race/social intimacy, parenting, adoption, abortion, and groups), our spiritual/religious beliefs, and birth control also have their places in the life stage to connect them to our ideas about shaping of our views. The following exercises family and parenting, and consequently are designed to help you identify the pregnancy options and abortion. experiences that may contribute to your Exercise A-1: Examining the Role of present values about both the broad and Family and Social Groups on Our specific aspects of abortion. Again, it is hoped Values that understanding our personal beliefs about abortion will help us provide better care for The family or social group (i.e. heritage, extended women facing an unplanned pregnancy and family, adoptive family, socio-economic group) considering the option of abortion. The that we grow up in provides us with our exercises are divided into four categories: customary beliefs and early social values. We use external influences, personal experience these as a backdrop when we interact with others influences, and, with those in mind, a woman’s and form opinions as we mature. Depending life circumstances around her abortion. Finally, upon our personal temperament we may integrate we look at professional roles and responsibilities. these values automatically or challenge them at different points in our lives. These exercises and questions can provide you with insights as you work through them The purpose of this exercise is to reflect on the alone. Discussing your reactions to and source and influence these core beliefs have on thoughts about them with others can also your present ideas about parenting, abortion, and expand your insights through shared and adoption. different experiences.

1. a) Did the family you were brought up in b) Does your present socio-economic group discuss specific values around parenting, differ from that of the family you were adoption, or abortion? ____ Yes ____ No brought up in? ____ Yes ____ No If yes, describe: ______If yes, has this affected your views about ______parenting, adoption, or abortion? ______b) Were there any family events that changed these views while you were living 4. Which social group would you consider has with the family? ____ Yes ____ No been the predominant influence on your If yes, describe: ______values on parenting, adoption, and ______abortion? ______Heritage/race ____ Socio-economic ____ Family ____ c) Describe any similarities or differences between the values you presently hold 5. a) Choose one of the options in each about parenting, adoption, or abortion and category that would be the most your family’s values about parenting, encouraged by your predominant social adoption, or abortion. ______group. ______Number of Family Age of new ______children forms parents ❑ 0 child ❑ single parent ❑ Teenage parents 2. Did your family’s values reflect your race/ ❑ 1 child ❑ two-parent ❑ Parents age 20-30 heritage or nationality’s values? ❑ 2 children ❑ multigenerational ❑ Parents age 30-40 in household ____ Yes ____ No ❑ 3-4 children ❑ same-sex parents ❑ Parents age 40-50 If no, how did they differ? ______❑ 5+ children ❑ single gay parent ______b) Does this represent your present life experience? ______3. a) Did the socio-economic group you were In what ways, if any, has this caused brought up in have any influence on your conflicts with your family? ______values about parenting, adoption, or ______abortion? ____ Yes ____ No ______If yes, describe its influence:______

6. a) Do your current values differ from the 1. Have you held the same spiritual beliefs values you were brought up with in any of since childhood? ______the following areas? Check any that apply. ______❑ large families ❑ small families ❑ family on welfare ❑ role of women ❑ role of men ❑ mothers working ❑ birth control ❑ adoption ❑ abortion 2. How often, on average, during a day, do ❑ daycare ❑ divorce ❑ blended families you consciously refer to your spiritual ❑ sex before ❑ mixed race ❑ marrying outside beliefs before making a decision? After marriage parents of culture making a decision? ______b) If your values differ, what influenced the ______change? ______3. Have you been challenged by life ______circumstances that called on actions not supported by your religious or spiritual 7. What percentage of your current ideas beliefs? Were you able to reconcile these about family is culturally (family/social actions with your beliefs at a later date? group) influenced? ____ Influenced by Did you do this on your own or with personal experience? ____ Other? ____ support?______Exercise A-2: Examining the Role of ______Spiritual Beliefs on the Formation of Our Values 4. Do your beliefs about any of the following Our spiritual or religious beliefs may be rooted in topics that are influenced by your spiritual our family or arrived at independently during values conflict with anyone in your life at different points in our lives. Some people consider present? these private contemplations while others share these Beliefs about family? ___ Yes ___ No beliefs openly in their everyday interactions. The Beliefs about social roles? ___ Yes ___ No merging of political and spiritual ideals in society Beliefs about sex? ___ Yes ___ No has historically been a difficult marriage. The Beliefs about birth control? ___ Yes ___ No purpose of these questions is for you to reflect on the Beliefs about abortion? ___ Yes ___ No role of your spiritual beliefs in your everyday life. If yes, how have you reconciled these Take a moment to reflect on the following differences? ______questions and take note if these raise any ______other issues for you. ______

Exercise A-3: Examining the Role of when you were 18? Describe how your Life Stage on the Formation of Our views have changed since that time._____ Current Views ______Our age influences our reactions to life and ______change. Youth provides us with optimism, easy ______access to childhood memories, and endless possibilities but it can also limit our broader 4. Have your views about the choice of not understanding of the impact of our decisions. having or having children changed since Additional years bring us the perspective you were 18? Describe: ______provided by an accumulation of experiences but ______the depth of this perspective is dependent upon ______their range and the personal insights we have ______about these experiences. The purpose of these questions is to remind us to pay attention to the 5. How does your present age affect your influence of our age on our understanding of our perspectives when discussing pregnancy clients’ dilemmas and the fluid nature of our options with a patient? ______perspectives throughout our lives. ______1. How did you feel about romantic relationships when you were 16? 25? 35? Section B: The Role of Our Personal 45? Describe the differences: ______Experiences in the Formation of Our Values ______We have raised questions about the external ______influence of family and social culture, age, and ______spiritual values on the formation of our values. In the following exercises we explore how our own 2. What do you think would be the ideal age experiences (and those of our intimate others) for a woman to have her first child? Have with sexual intimacy, and our histories with your views changed about this since you pregnancy, fertility, infertility, adoption, abortion, were 18? Since you were 30? 40? 50? What and parenting can also influence our perspective. influenced these changes? ______Exercise B-1: Examining Our Own ______Experiences with Sexual Intimacy and ______Risk-Taking. ______Because the need for an abortion always begins with 3. What did you think of teenage pregnancy, the act of sex, it is important to be aware of our adoption, single parenting, and abortion underlying attitudes about this topic. Depending upon our own personalities, our sexual identity and experiences are often deeply personal and not often

discussed with others. We gather information through 4. Which of the following have had an our own experiences, what we read and see in the impact on your sexual or intimate media and literature, and from stories gleaned from relationships: our social circle. Take a moment to reflect on the Sexual abuse or sexual assault ______following questions and ask yourself if any of these Coerced sex ______experiences affect how you would consider a patient’s Sexual infidelity ______sexual history and its role in her pregnancy. (yours, partner’s, parents’) Infertility or fear of infertility ______1. Was your first sexual intimacy well planned Sexually transmitted disease ______or spontaneous? Was birth control an issue? One night stand ______Given your present perspective, is there Unplanned pregnancy ______anything you would change about that Abortion ______experience? If yes, describe. ______Drugs or alcohol ______5. Which of the topics listed in #4 above ______would you feel the most comfortable discussing with a client having a similar 2. How healthy is your own sex life at experience in her own life? ______The present? Is there anything you would like least comfortable? ______to be different? If you are unable to make any changes, how has this affected your life 6. Describe how your experiences (or lack of) at present? Describe:______influence your discussions with clients in a ______positive way. ______

3. Have you always had a sexual partner 7. Describe how your experiences (or lack of) during your adult years? If not, what was influence your discussions with clients in a the longest period of time you went negative way. ______without sexual intimacy? Describe any ______effects it had on your life at the time. ______8. What strategies would you use to improve ______your comfort level with these topics if they impacted the life of one of your clients?______

Exercise B-2: Examining Our Own Have any of these experiences complicated or Experiences with and Views about assisted in your ability to understand your Parenting, Adoption, Abortion, and clients’ choices? If yes, describe: ______Pregnancy Prevention ______Not all of us become parents, but many of us have ______had experiences and/or risks with pregnancy. Our experiences often affect how we see others in 2. Which, if any, of the following have you had similar situations. Think about your responses to personal experience with in the role of child these questions and your present ideas about the or family member? (check all that apply) challenges of parenting, adoption, abortion, and Welfare ______pregnancy prevention. Mental health problems ______Drugs and alcohol abuse ______Parenting Prenatal health risk by mother ______Our experiences with parenting color the way we Single parenting ______see it as an option for women. It is important to Divorce/blended families ______acknowledge our own experiences to help us be aware of our biases. Was your experience as a parent or child compromised in any way by these issues? 1. If you do not have children, which of the Describe: ______following statements would apply to you? ______(check all that apply) ______Do not want to have children ______Not ready to have children ______How have you coped with these experiences? Infertility/difficulty conceiving ______Lack of opportunity ______Do not want to be a single parent______Financial reasons ______Have any of these experiences complicated or Health reasons ______assisted in your ability to understand your Career goals ______clients’ choices? If yes, describe: ______Placed a child for adoption ______Loss of a child ______Undecided ______Other ______3. Would you or others view your parents/ family as the “perfect” family? ______If any of the above reasons have created stress If yes, describe the impact on your present in your life, describe how you have coped. views on parenting and family. ______

4. If you are a parent, have you experienced Considered adoption when ______any of the following with your child I or my partner became pregnant (children)? (check all that apply) Work(ed) in the adoption field ______Health challenges ______How have these experiences affected your Mental health issues ______personal life? ______Drug addictions ______Financial challenges ______Single parenting ______Have any of these experiences challenged or Divorce ______assisted in your objectivity as a health Death of a child ______professional when counseling a woman about pregnancy options? If yes, describe: ______How have you coped with these experiences? ______

2. If you have no personal experience with Have any of these experiences complicated or adoption, has your objectivity been assisted in your ability to understand your challenged as a health professional when clients’ choices? If yes, describe: ______counseling a woman about pregnancy ______options? If yes, describe: ______Adoption Fewer of us have personal experience with adoption Abortion than we do with parenting. As with parenting, it is Our experiences with abortion vary. It is important to acknowledge how our experiences or important to assess where our experiences are lack thereof may influence our views of this option. derived from and the influences they may have on our objective understanding of other women’s 1. If you have a personal experience with choices. adoption, which of the following apply? (check all that apply) 1. If you have experience with abortion, I am adopted ______which of the following apply? (check all Family member/friend is adopted______that apply) Placed a child for adoption ______Family/friend placed ______My partner or I have had an abortion ____ child for adoption I have accompanied a family member ____ Trying or tried to adopt ______I have accompanied a friend ____ Family member/friend ______I am aware that a family member and/ adopted a child or close friend has had an abortion ____

My partner or I have considered 3. If you have no personal experience with abortion because of pregnancy ____ abortion, has this had any effect on your role as I work in the abortion field ____ a health care professional counseling a woman My family or I picket at about her pregnancy options? If yes, describe: abortion clinics ______Which of the above (if any) have had the most impact on your views on abortion? Pregnancy Prevention ______Our attitudes about abortion sometimes have ______links to our views on the preventative side of pregnancy. Birth control failure, absence, or Have any of these experiences challenged misuse is a complex topic too often simplified if or assisted your objectivity as a health care we do not address the complexity of individual professional when counseling a woman about personalities, the power dynamics of relationships, her pregnancy options? If yes, describe: cultural differences, and women’s experiences with ______the side effects of medications. Take a moment to ______reflect on your own experiences and evaluate these in relation to your views on pregnancy 2. If you or your partner has had an abortion, prevention. describe the most difficult aspects of this decision. ______1. Considering your own experiences with ______birth control methods, have you experienced any of the following? (check all Describe the positive aspects of this decision. that apply) ______Difficulty accessing birth control ______Parental disapproval ______Partner conflict ______If you could, what would you have changed Financial difficulties ______about the experience? ______Misinformation ______Compliance difficulties ______Lack of preparation ______Have any of these experiences challenged or Failure of method ______assisted your objectivity as a health care Medical contraindication ______professional when counseling a woman about Use influenced by drugs or alcohol______her pregnancy options? If yes, describe: ____ Assumed partner was using ______Cultural difference ______

If yes, how did you solve these problems? 3. Would you describe yourself as a risk taker ______in general? ____ Yes ____ No ______Do you take risks with your health? ___ Yes ___ No If you have been pregnant, how many of your Smoker? ______pregnancies are the result of any of the above Overweight? ______difficulties with birth control? ______No exercise? ______Seatbelts? ______2. Have you or your partner experienced any Sunscreen? ______of the following side effects from a birth Drive too fast? ______control method? (check all that apply) Always practice safe sex? ______Allergic reaction ______Safe oral sex? ______Weight gain ______Regular pap or other Mood changes ______routine tests? ______Irregular bleeding ______Ask potential partner about STD’s Nausea ______before sex? ______Pain ______Have you taken risks with Change in sexual performance ______birth control? ____ Often? ______Acne ______Have you discussed this with a health Change in sexual pleasure ______professional? ______Change in libido ______Do you follow the same birth control advice you If yes, how many times have you changed give to clients you counsel? ___ Yes ___ No your method? ______If no, why not? ______Has this caused stress in your life? If yes, ______describe: ______Have your experiences strained or assisted ______your objectivity when you discuss birth control and pregnancies with clients? If yes, describe: ______

Section C: Self-Evaluation of Our At viability _____ Objectivity When Considering a Woman’s At the end of the second trimester _____ Pregnancy Circumstances and Her Options At some point in the third trimester_____ When a woman presents with a pregnancy and It depends on the reason for is examining her options, her circumstances will the abortion _____ play a role in her decision. It is natural for a health care provider to be evaluating her choice 3. Now consider this list again as it relates to along with her in order to provide objective and your comfort level with three varying respectful professional care. It is important to degrees of your professional involvement in examine our own comfort level with her choice abortion. At what point do you feel and consider our reactions when our neutrality uncomfortable with: is challenged. We will begin by looking at the a) making abortion referrals for patients option of abortion and our personal responses b) assisting with the provision of abortion to issues such as gestational age, and then services follow with the circumstances of the individual woman who is making this decision. c) providing abortions

Exercise C-1: Examining Our Comfort Write your reasons for feeling this way about Level with Gestational Age gestational age. How long have you felt this way?______For some people the acceptability of a patient’s ______abortion decision is dependent on the stage of ______pregnancy at which the abortion might take place. This exercise is designed to help you examine your If you had different cutoff points depending own feelings about this very personal question on the level of your involvement in providing and its possible influence on the exercises to follow. services, what are the reasons for these differences? If your feelings were consistent 1. Does gestational age affect how you feel across the different levels of involvement, about your patient’s abortion decision? what are the reasons for this? ______Yes ____ No ______2. If gestational age does affect your response, at what point do you feel uncomfortable with your patient’s abortion decision? At conception _____ At implantation _____ At the end of the first trimester _____ At quickening (i.e. point of fetal movement) _____

Exercise C-2: Examining Our Comfort ___ to end a pregnancy if the woman Level with Circumstances of Each does not want any more children Woman’s Abortion Decision ___ to end a pregnancy if the woman is Sometimes we are comfortable with one woman’s not financially able to care for a abortion decision, but are challenged by the child circumstances surrounding another woman’s decision. ___ to end a pregnancy if the woman This exercise is designed for you to reflect on your feels she is not ready for the personal responses to the following situations. It also responsibility of having a child illustrates the wide range of circumstances that may ___ to end a pregnancy if a child would influence a woman to decide to have an abortion. interfere with educational or career goals ___ I can accept a woman’s abortion decision ___ to end a pregnancy if the woman is in any circumstance when she has made unready for how a child could an informed and voluntary choice for change her life abortion. ___ to end a pregnancy if the woman is ___ I can accept a woman’s abortion decision very young in certain circumstances including: (check ___ to end a pregnancy if the woman has all that apply) not had a previous abortion ___ to end a pregnancy that threatened ___ to end a pregnancy because of gender her life ___ other(s): ______to end a pregnancy that threatened ______her physical health ______to end a pregnancy that threatened her mental health ___ I find abortion unacceptable under ___ to end a pregnancy involving virtually any circumstances. significant fetal abnormality ___ to end a pregnancy resulting from What are the reasons for your beliefs? How rape or incest long have you held these beliefs? ______to end a pregnancy resulting from ______birth control failure ______to end a pregnancy if the woman is ______unmarried ______to end a pregnancy if the woman is in an unstable relationship or is not in a relationship

Exercise C-3: Individual Cases: ___ 22 year old carrying a fetus with Examining Our Potential Biases severe deformity Parts 1 and 2 of this exercise individualize the ___ 24 year old heroin addict who already circumstances of a woman’s abortion decision by has three children in state custody providing more details to expose the complexity of ___ 26 year old single mother who has a the decision. By putting yourself into the role of the young child with leukemia health care professional responsible for providing ___ 30 year old with 2 children whose access to abortion to only one of the following husband died recently in a car crash women, you are challenged to examine your personal views and to experience the difficulties What factors influenced your choice? How associated with limited access on the health did it feel to have to make this choice? professional as well as the patient. This exercise ______also illustrates the difficulty with comparing one ______patient’s circumstance with another. Until we are put in this position we may assume that 2. The six women described below have come determining a hierarchy of needs would be difficult to you requesting a referral for abortion. but not impossible. Pay attention to your reactions Due to circumstances beyond your control, to this challenge when putting yourself in the role only one more abortion can be done and of the decision-maker. Part 3 helps us identify our you must choose which one of your six personal discomfort, if any, when faced with the patients is to receive the last abortion. circumstances of some women’s abortion decision. Rank the cases from 1 (most want to refer for an abortion) to 6 (least want to refer). 1. Before Roe v. Wade legalized all first __ Gloria is 14 years old, unsure about trimester abortions in the U.S., some what to do. She has supportive parents. hospitals provided a very limited number of “special case” legal abortions. Hospital __ Louise is 19 years old, has two children therapeutic abortion committees had the and has had two previous abortions. task of determining which cases were __ Selma is 24 years old, a student in worthy of being granted a safe, legal medical school and engaged to be abortion. You are on that committee and married. She wants to begin her career must determine which ONE of the before starting her family. following patients, all of whom are __ Eileen is 29 years old, single and requesting an abortion, will be granted the pregnant with an IUD in place. one remaining legal abortion left in your __ Margaret is 35 years old, divorced, yearly quota. pregnant from a one-night encounter, ___ 12 year old incest victim her first sexual experience following her ___ 15 year old rape victim divorce.

__ Dorothy is 45 years old, married with Selma: She is clear that she wants to three grown children. Neither she nor concentrate on her career and her new her husband wants any more children. marriage before starting a family. Response: ______What guided your choice for number 1? ______Eileen: Her IUD failed and she is now faced What guided your choice for number 6? with an unplanned pregnancy. She is also ______single and may not have the support she ______needs to raise a child.

Was making your choices difficult or easy for Response: ______you? Explain.______Margaret: She is already coping with a high Below are some of the arguments often made level of stress because of her divorce. To have for each of the women. In each case, if you a child without the emotional and financial needed to argue for your choice, how would support of a partner would be very difficult. you respond to or refute these arguments for She is clear that she does not want to have a the women you did not choose? child under these circumstances. Response: ______Gloria: She’s just beginning her life and ______should have a chance to enjoy her childhood. ______She will have few coping skills and the child might suffer. At her age, childbearing could Dorothy: She and her husband are both be damaging to her health. clear they do not want another child and feel Response: ______their family is complete with their three ______grown children. Additionally, at her age, the ______pregnancy is high risk.

Louise: She has her hands full with two Response: ______children at such a young age. Her previous ______two abortions indicate she is clear about not ______wanting another child. Response: ______

As a health care professional, how do you What factors influenced your choice? How did it think you would react to having to make feel to make this choice? How might you handle choices like these? What unique qualifications your discomfort in dealing with this patient? do you have to make such choices? ______3. Even health care providers who self-identify as pro-choice and are supportive of their Exercise C-4: Pregnancy Options patients’ decision-making autonomy can be Decision Making faced with circumstances that ‘push their Each woman with a pregnancy decision to make buttons’ and challenge them personally and has to consider her obligations to herself, the impact professionally. This exercise helps to identify of her decision on her family, partner and the the areas where you area most challenged. children she already may have. This exercise is designed to involve you in the intricacies of I would feel most uncomfortable referring or balancing priorities in the decision-making process providing an abortion for a woman who: of a woman examining her options. The effort of ___ is ambivalent about having an abortion prioritizing and selecting options forces us to expose but whose partner wants her to terminate our internal biases and challenge our neutrality. the pregnancy ___ wishes to obtain an abortion because she You have been given the authority to decide is carrying a female fetus the outcomes of the following six pregnancies. ___ has had what I consider too many Only two of the women can carry their previous abortions pregnancies to term and become parents, only two can make arrangements for adoption, and ___ shows little emotion about becoming only two can obtain abortions. You must make pregnant and choosing abortion these decisions and be able to justify them. ___ has indicated that she does not want any birth control method to use in the future Jane is 17 years old and is 10 weeks pregnant. ___ is a regular protestor at abortion clinics but She comes from a supportive, working class feels her circumstances are different from family with strong ties to the anti-abortion those of other women seeking abortion. movement. She has been accepted on an ___ is nearing the end of her second trimester athletic scholarship to the University of Pennsylvania and is due to start her first semester there in two months. Her boyfriend wants them to get married and have the baby.

Mary is a 26-year-old lawyer and is 6 weeks is ready to be a mother. She and her pregnant. She and her boyfriend are planning boyfriend, who is 17, have been together for 8 to get married in a few years. She has high months. His parents are not very happy that aspirations for her career and is uncertain their son is with Tina. whether she wants children at all. Which two women would you choose to Ruth is 34 years old, married with 3 children. continue their pregnancies and become parents? She had just ended a month long affair and ______had committed herself to her marriage when ______she discovered she was pregnant. She is ______unsure with which man she became pregnant. Her husband is very loving and supportive What factors influenced your decision? but is unaware of his wife’s involvement with ______another man. ______Leslie is 21 years old and is midway through the first semester of her last year of college. Which two women would you choose to She is working 2 jobs to pay for her tuition continue their pregnancies and make and expenses and is just barely getting by adoption arrangements? ______financially. She has been with her partner for ______2 months and is not sure where the ______relationship is going. Before she found out ______she was pregnant, she was thinking about breaking things off. What factors influenced your decision? ______Sue is 37 years old and married. She and her ______husband had been trying to get pregnant for ______3 years. She just got back the results of her amniocentesis and they indicate that the baby Which two women would you choose to has a severe genetic abnormality. She is 16 obtain abortions?______weeks pregnant. ______Tina is 14 years old. Although she wasn’t really planning to get pregnant, she was What factors influenced your decision? excited when the test came back positive. She ______hasn’t told her parents yet because she knows ______that they will be angry and will not think she ______

Exercise C-5: Parenting and Adoption: Kaiya is 36, has 3 children, all girls, ages 8, 6 Examining our Biases and 4. She has not imagined having more Our biases about parenting and adoption can also than 3 children but her husband is hopeful challenge our neutrality when listening to the that this pregnancy will be a boy. She feels circumstances of a woman’s pregnancy. This her husband’s wishes are important and is exercise is designed for you to examine your own sympathetic to his desire for a boy. They are responses to the following circumstances involving in a secure financial position. the choices of parenting and adoption to discover very very areas where you are the most and least comfortable. comfortable uncomfortable Our awareness of these “hot buttons” allows us to Liza is 30, pregnant for the first time. She has review how we would manage our feelings and not told her husband she went off birth control responses in a professional role with women and to because he says he is not ready for children and ensure respectful and non-judgmental care. will be ready in a year or two. She states she is sure he will change his mind. She says she Indicate your first emotional responses to each would not be emotionally or financially woman described below choosing to prepared to single parent. continue her pregnancy and become a parent and circle the corresponding spot on very very the line to identify your feelings. comfortable uncomfortable

Karen is 46, broke up with long term partner Cindy is 20, has been unsuccessful in her who doesn’t want a child, will have to go on attempts to overcome her cocaine addiction welfare, but has always wanted a child. She of two years. She has one child in foster care. has limited family support and has a history She is on welfare and does not have a steady of depression, although it is now controlled boyfriend. with medication. very very very very comfortable uncomfortable comfortable uncomfortable

Sarah is 16, living at home with her adoptive parents. Her birth mother was 13 when she gave her up for adoption. She feels she would be disloyal to her birth mother if she did not go through with the pregnancy because her mother continued her pregnancy. very very comfortable uncomfortable

Indicate your first emotional responses to each Anna is a single parent of two children. She woman described below choosing to had sex with ex-husband who is remarried. continue her pregnancy and make adoption She says she cannot afford another child and arrangements and circle the corresponding does not feel comfortable with abortion. She spot on the line to identify your feelings. has not told her ex-husband about the pregnancy. She says she has decided to place Jen, age 28 has just found out she is 14 weeks the baby for adoption to a distant relative. pregnant. She was adopted at birth by an very very older North American couple who brought comfortable uncomfortable her from South America. She is an artist, her boyfriend is a student, both are carrying large Tiffany, age 15, wants to continue her student loans. She feels she has a pregnancy and place her baby for adoption to responsibility to her birth mother to go a loving couple she met at her friend’s church. through a pregnancy and place her baby for Her parents are upset and “want to talk some adoption. Her partner tries to remain neutral sense into her.” They believe it is in Tiffany’s but is visibly very upset. best interest for her to have an abortion. very very Tiffany says she is not ready to be a parent comfortable uncomfortable and does not “believe” in abortion. very very Vicki, age 28, has a history of mental health comfortable uncomfortable problems but is capable of making her own decisions. She is 15 weeks pregnant and has April, age 33, has recently broken up with her not told the man involved in the pregnancy boyfriend. She is devastated about the that she is pregnant. She is canceling her pregnancy but she does not think she could abortion appointment because she has seen a reconcile abortion with her spiritual beliefs. TV show about women who can’t have Her friends and family are trying to influence children and she was very moved by their her to continue the pregnancy and raise the plight. She has decided she would like to child with their help but she thinks she would place her baby for adoption to help infertile not be able to provide a life that she has couples. imagined for a child. She has decided to place very very her baby for adoption. Her boyfriend is upset comfortable uncomfortable but does not want to become a parent. very very comfortable uncomfortable

Section D: Providing Abortion Care: Professional Values Clarification Exercises Evaluating our professional obligations in all cases as we are presented with them can be a challenge. It can help if we take the time to ask ourselves some questions about the relationship between our personal views and our professional role beforehand as we make decisions about providing access to safe abortion services. Providing access can include providing referrals to appropriate services or providing abortions. As a health care provider, your decision about providing abortion services ultimately determines whether women can access safe abortion care. As such it is important to assess your feelings about abortion and providing abortions in the context of your professional role and obligations. While in many countries physicians have traditionally been the providers of legal abortion care, the availability of medical abortion, also referred to as medication abortion, has opened doors for other health care professionals, for instance nurse practitioners and midwives, to play a larger role as providers of abortion care. Additionally, more physicians in specialties such as family medicine, primary care, and adolescent medicine are exploring ways to incorporate abortion care into their practices. In some cases, this has required practitioners to actively evaluate for the first time what it means to them to become an abortion provider. Exercises D-1 through D-4 are designed to help you critically examine the factors that might influence your choice to become trained and to provide abortion services. Although some of the exercises pertain specifically to clinicians who are deciding about becoming abortion providers, all health professionals, whether they are involved in abortion care specifically or provide care to women in other settings, may benefit from reviewing these questions. They are also intended to illustrate the possible consequences of your choice to provide or not provide abortion service.

Exercise D-1: Views about the Role of What do you think of this statement? What the Health Care Provider are the reasons for your position? ______A physician who practiced before the 1973 ______U.S. Supreme Court Roe v. Wade decision that ______struck down state laws prohibiting abortion says that she occasionally lied to colleagues on Exercise D-2: Personal Assessment of the hospital committee about a patient’s Professional Obligations medical circumstances in order to help Building on your thoughts from Exercise D-1, patients obtain legal abortions. She states what obligation do you have as a health care “That’s part of the practice of medicine…you provider to ensure that your patients can access do what you feel is necessary to insure the safe abortion services? Check all that apply. safety of your patients.” ( Joffe1, p. 72). ___ I have an obligation to talk my pregnant patients out of obtaining abortion services.

1Joffe C. Doctors of Conscience: The Struggle to Provide Abortion Before and After Roe v. Wade. Boston: Beacon Press, 1995

___ I have no obligation to my patients with ___ Desire to provide comprehensive care for regard to abortion services. my patients ___ I have no obligation to provide abortion ___ Need for a provider for patients in the services for my patients as long as other community where I practice clinicians can do so. ___ Commitment to help my patients avoid ___ I have an obligation to provide factual the risks of self-induced, illegal, or poor information about all pregnancy options quality abortions to my patients. ___ Belief in the rights and responsibilities ___ I have an obligation to provide my of my patients to make their own moral pregnant patients with referrals for services choices I am not willing or able to provide. ___ Desire to see only wanted children ___ I have an obligation to follow up on brought into the world abortion referrals I make to ensure that ___ Commitment to providing my patients my patients have been able to access safe, with the care they need, rather than high quality care. referring them out to a provider they do ___ I have an obligation to provide whatever not know legal care my patients need and that I am ___ Desire to be competent in as many competent to provide, as long as it does aspects of reproductive health care as not conflict with my personal beliefs. possible and thus expand my ___ I have an obligation to provide whatever marketability and my career opportunities legal care my patients need and that I am in this field competent to provide, regardless of my ___ Desire to provide the same opportunity personal judgments about their choices. to obtain safe abortion services as I/my partner had when I/she needed an Write the reasons for your views. How long abortion have you felt this way? ______Commitment to ensuring availability of ______legal medical services for my patients ______Desire to make a public commitment to abortion rights Exercise D-3: The Decision to Provide Abortion Care: Motivations and ___ Desire to foster a supportive environment Obstacles for abortion rights and abortion providers within the medical community 1. Motivations: ___ Other(s): ______Which, if any, of the reasons listed below ______might motivate you to provide abortions for ______your patients? Check all that apply.

2. Obstacles: Exercise D-4: Overcoming Obstacles Which, if any, of the reasons listed below to Providing Abortion Care: might deter you from providing abortions for A Self-Evaluation. your patients? Check all that apply. Given the perceived and real difficulties facing those ___ I find the idea of abortion personally who choose to provide abortions, it is not surprising objectionable. that some clinicians choose not to become trained in ___ I believe that abortion is contrary to my abortion techniques or, even if they have been trained, oath to do no harm. choose not to provide abortions. At the same time, abortion providers have found ways to successfully ___ Abortion is contrary to my religious beliefs. overcome the obstacles they face. The following ___ I might have to face the memory of my exercise is intended to provide some suggestions to own previous abortion experience(s). help overcome obstacles to providing care and allow ___ I would worry about patients leaving my you to assess your feelings about these options. practice. ___ My partners in my practice and/or the Looking again at the concerns you checked hospital where I have admitting in Part 2 of Exercise D-3, consider ways that privileges are not supportive of or have a some health care providers deal with those policy against providing abortion services. issues. This exercise is two-fold: First, create ___ I would worry about my reputation with a hierarchy of your personal concerns by medical colleagues. indicating #1 as your biggest concern, and ___ There are administrative barriers (e.g. #12 as your smallest concern next to the list malpractice coverage, third-party of statements A-L. After you have established reimbursement, compliance with regulations this hierarchy, refer to suggestions for each about abortion practice and facilities). statement for further exploration. ___ Significant people in my life oppose A.____ I find the idea of abortion personally abortion. objectionable. ___ I would be concerned about my personal Suggestions for further personal exploration of safety vis-à-vis harassment and violence this topic: by those opposed to abortion. ___ I would be concerned about the safety of • Speak with abortion providers and learn my loved ones. how they deal with any discomfort they might have felt. ___ I am unsure about my competence if I • Learn more about abortion procedures to provide abortions only occasionally. pinpoint the source of this discomfort. ___ Other(s): ______• Shadow an abortion provider. ______• Observe some pregnancy options ______counseling sessions.

• Consider if there have there been other • Speak with supportive members in your times when you had personal objections religious congregation about how to to aspects of medical care. How did you reconcile this, if this is possible. deal with those objections? Where do • Examine other areas of your religion your objections stem from? that you may find contrary to your personal beliefs. How are you reconciling B.____ I believe that abortion is contrary to those issues? my oath to do no harm. Suggested resources: Suggestions for further personal exploration on Materials from Catholics for a Free Choice this topic: (http://www.catholicsforchoice.org/), the • Speak with abortion providers and learn Religious Coalition for Reproductive Choice how they reconcile this. (http://www.rcrc.org/), or other religiously • Consult resources on the health affiliated groups that support abortion rights. consequences of illegal and inaccessible Life Matters: The Story of an Illegal Abortionist. abortion. A documentary. More information available at Suggested resources: http://www.filmakers.com/indivs/LifeMatters. htm Joffe C. Doctors of Conscience: The Struggle to Provide Abortion Before and After Roe v. D.____ I might have to face the memory of Wade. Boston: Beacon Press, 1995. my own previous abortion experience(s). Poppema S. Why I Am An Abortion Doctor. Suggestions for addressing this concern: Amherst, NY: Prometheus Books, 1996. • Share concerns with trusted others who Dorothy Fadiman’s Emmy-Award winning know about the experience or seek documentary trilogy From the Back Alley to professional counseling or a support the Supreme Court and Beyond. group to work to resolve feelings about Voices of Choice – A Multimedia Project from an abortion experience. Physicians for Reproductive Choice and • Reflect on the benefits of helping others Health. Information available at through something you have experienced. http://www.prch.org/voicesofchoice.shtml Suggested resources: C.____ Abortion is contrary to my religious DePuy C & Dovitch D. The Healing Choice: beliefs. Your Guide to Emotional Recovery After an Suggestions for further personal exploration on Abortion. New York: Fireside, 1997. this topic: Torre-Bueno A. Peace After Abortion: A Pro- Choice Self-Help Guide for Women and Men. • Speak with abortion providers and learn San Diego: Pimpernel Press, 1996. how they reconcile this. www.peaceafterabortion.com/

E.____ I would worry about patients leaving Suggestions for successfully addressing this obstacle: my practice. • Network with pro-choice colleagues in Suggestions for addressing this concern: your hospital and build support for • Keep a low profile (e.g. separating an providing abortion services. abortion practice in time or space from • Network with colleagues in other the rest of one’s practice). hospitals who have successfully addressed • Use careful language (e.g. D & C rather policy restrictions. than abortion). • Use this guide as a starting point for • Educate patients about why this is an discussion with colleagues. important part of medical practice. • Reach out to pro-choice groups and • Network with colleagues who offer individuals in your community or region abortion to learn about the effect it had to build support. on their practices. • Join a pro-choice professional • Network with pro-choice groups, colleagues, organization. or organizations to build support. • Consider adding abortion-related services • Consider that offering abortion services first, such as post-abortion follow-up could signal to other patients that you are visits, options counseling, or even open to all their concerns and lead to information brochures about abortion better patient-provider relationships. and pregnancy options. • Consider that you may also gain new • Consider assisting in a local clinic one or patients who come to you for abortion two days a week. care and stay with you. Suggested resources: Suggested resources: The Center for Reproductive Health The Access Listserv is a network of family Education in Family Medicine website has physicians who are interested in the tools for beginning a dialogue with integration of early abortion services into colleagues and staff, including staff attitude family practice. Contact grouponata@ surveys at www.reprohealthfamilymed.org. hotmail.com for more information. G.____ I would worry about my reputation The Center for Reproductive Health Education with medical colleagues. in Family Medicine has information about talking with patients about abortion services Suggestions for successfully addressing this concern: at www.reprohealthfamilymed.org. • Network with pro-choice colleagues. • Avoid discussing abortion with your F.____ My partners in my practice and/or the other colleagues. hospital where I have admitting privileges are • Join a pro-choice professional not supportive of or have a policy against organization. providing abortion services. • Speak out effectively in favor of abortion.

• Maintain an open mind and a willingness TEACH Trainers Collaborative Working to talk to all colleagues, regardless of Group.* Early Abortion Trainers Workbook. choice stance. UCSF Center for Reproductive Health Suggested resources: Research & Policy: San Francisco, CA (2004). * Hufbauer E, Schwarzman M, For suggestions for responding to common Curington J, Robinson S, Hastings J. questions or comments people make about Available at http://www.ansirh.org/ providing abortion services, an excerpt from trainingworkbook/trainingworkbook.html “When People Ask ‘Where Do You Work?’” (Baker A. Abortion and Options Counseling: A The Center for Reproductive Health Comprehensive Reference, Revised and Education in Family Medicine has Expanded Edition. Granite City, IL: Hope numerous administrative resources available Clinic For Women, Ltd., 1995) is available at at www.reprohealthfamilymed.org. http://www.ansirh.org/trainingworkbook/cha pter9tools/Talking%20About%20Your%20W I.____ Significant people in my life oppose ork%20With%20Others.doc abortion. Suggested ways to handle these concerns: H.____ There are administrative barriers (e.g. • Do not discuss this aspect of your work malpractice coverage, third-party reimbursement, with them. compliance with state regulations about • Listen to and acknowledge their sources abortion practice and facilities). of discomfort. Strategies to address these issues: • Discuss with them the reasons for your • Network with colleagues who provide decision to provide care. abortion services. • Provide written and media resources for • Speak with staff of organizations that them to consider on the topic of abortion have expertise with abortion regulations, and abortion providers. such as the National Abortion Federation, • Be willing to discuss areas where you may The Center for Reproductive Rights, and also feel some discomfort. Perhaps it is the the American Civil Liberties Union. same area and your reconciliation of the • Join a pro-choice professional organization, issue may help them understand your work. such as the National Abortion Federation, for professional expertise. J.____ I would be concerned about my • These barriers exist for other areas of personal safety vis-à-vis harassment and medical practice, too. You or your staff may violence by those opposed to abortion. have already found ways to solve these issues. Suggestions for addressing this concern: Suggested resources: • Keep a low profile about your involvement See Chapter 9 “Office Practice” in Goodman in providing abortion services. S, Paul M, Wolfe M, Stewart FH and the • Study and assess the personal risk.

• Take extra personal security measures as • Establish relations with the local police. well as for offices or clinics. • Reach out to pro-choice groups and • Establish relations with the local police. individuals in your community or region • Network with pro-choice organizations, to build support. such as the National Abortion Federation, • Stop doing procedures if the threat felt that can provide help when needed. too great. • Reach out to pro-choice groups and Suggested resources: individuals in your community or region See Suggested resources under J above to build support. • Stop doing procedures if the threat felt L.____ I am unsure about my competence if I too great. provide abortions only occasionally. Suggested resources: Some suggestions: Security staff at the National Abortion • Refer patients elsewhere if at all doubtful. Federation work closely with providers on • Obtain additional experience by working issues related disruption, harassment, and occasionally at an abortion clinic. violence and provide security trainings, • Find a skilled provider in the community assessments, alerts, and 24-hour clinic support. to work with you or provide extra training. The website for the U.S. Department of • Participate in continuing medical Justice National Task Force on Violence education courses about abortion and Against Health Care Providers includes abortion techniques. information about the enforcement of laws • Consider offering medical abortion as an to protect reproductive health care providers alternative to vacuum aspiration until you and their patients, as well as security tips at feel competent with aspiration skills. http://www.usdoj.gov/crt/crim/faceweb.htm • Stop or scale back the scope of De Becker, G. The Gift of Fear: Survival procedures if you did not feel confident Signals that Protect Us from Violence. Gavin in your competency. De Becker, 1997 Suggested resources: The National Abortion Federation’s website K.____ I would be concerned about the safety (www.prochoice.org) includes extensive of my loved ones. professional education resources and Suggestions for addressing this concern: materials, including an online CME • Keep a low profile about your involvement program on medical abortion, information in providing abortion services. about training opportunities, and links to • Study the facts and assess for yourself other organizations that provide training or whether your family would be at risk. have educational resources. • Ask your loved ones not to discuss your work.

PART III – ADDITIONAL INSTRUCTIONS FOR USING SELECTED EXERCISES FROM THE GUIDE IN A GROUP SETTING

Facilitating group exercises and group initial thoughts. The way we expand our discussion can be a daunting task, particularly thinking and grow is by receiving more when the subject under discussion is one information from other viewpoints that make about which people have strong and personal a lot of sense to us – it doesn’t matter if we feelings. At the same time, however, the didn’t think of it first. So feel free to let new group process is invaluable in terms of thinking change your mind at any time. clarifying one’s own values and learning from others. Included at the end of this section is a Exercise C-1: Examining Our Comfort list of resources for those who would like Level with Gestational Age: more guidance and information about the (Suggested time allotment: 30 minutes) process of facilitating group discussions. Draw an imaginary line across the room and label the following points on the line: at What follows are 1) tailored instructions for conception, at implantation, at the end of the using in a group setting selected exercises first trimester, at quickening, at the end of the from Part II that are most appropriate for this second trimester, at some point in the third forum and 2) additional questions for trimester. Ask participants to stand on the prompting group discussion. We have line at the point where they stop feeling included an estimate of the approximate time comfortable with the idea of abortion. Ask to allow for completing each exercise. participants at different points along the However, the timing of these exercises continuum to share what made them choose depends very much on a number of factors their position while others in the group just including the size of the group, the level of listen. Afterwards, open up the floor for participation, the diversity of opinions held by general discussion and reactions to the ideas participants, and the dynamics among the that were expressed. Repeat for different participants. levels of professional involvement in abortion: 1) making abortion referrals, 2) assisting with Finally, it might be helpful to set the tone for abortion services, and 3) providing abortions. group sessions by indicating that there is no need to reach group consensus, but striving to understand each other’s views can be very useful. Further, hearing the ideas of colleagues might cause participants to reconsider their

Exercise C-2: Examining Our Comfort 1) What was most difficult about this exercise? Level with Circumstances of Each 2) What was your reaction to the list of Woman’s Abortion Decision: circumstances under which someone might (Suggested time allotment: 45 minutes) find abortion acceptable? Did it seem like a Conduct an anonymous poll by having wide range or did you expect a more participants write agree or disagree in response extensive list? to five statements you have selected from the 3) Which circumstances seemed easiest to range of possible feelings about women select or rule out? For what reason? obtaining abortions (e.g. I can accept a 4) What are the possible reasons why the woman’s decision in any circumstance when debate about abortion so often focuses on she has made an informed and voluntary the woman’s life, rape, and incest rather than choice for abortion, I can accept a woman’s on other circumstances which might be decision to end a pregnancy that threatened more common? her physical health, I can accept a woman’s decision to end a pregnancy if she is in an Exercise C-3: Individual Cases: unstable relationship or is not in a relationship, Examining Our Potential Biases I can accept a woman’s decision to end a Part 1 and 3 pregnancy if she is very young, I find abortion (Suggested time allotment: 1 hour) unacceptable under virtually any circumstance). For each exercise, label stations around the room Collect the papers and redistribute them so with the case descriptions for the exercise. Ask each participant has someone else’s answers in participants to go to the station that represents front of them. Designate one side of the room their choice and discuss with others at the same as “agree” and one as “disagree,” then read each station their reasons for so choosing. After all statement and have participants go to the side stations have reported back to the full group of the room corresponding to the answer on their reasons, participants can change stations if the sheet of paper they are now holding. After they have changed their choice. Then ask the each statement, ask a few participants from full group to talk together in an effort to reach each side of the room to give a rationale for consensus. Repeat for Part 3, although there is that position, reiterating that the person no need to reach consensus on this one. offering the explanation does not necessarily hold that opinion. After a few people from Discussion questions: each side of the room have offered a rationale 1) Which choice was hardest to make (denying for that position, open it up to general abortion access in cases where an abortion discussion so participants can respond to the might be judged as generally socially ideas which were expressed. acceptable OR providing abortion in cases Possible discussion questions if participants are where abortion might be judged as socially not talking: unacceptable)? Why?

2) How can a clinician handle personal Exercise C-4: Pregnancy Options discomfort in dealing with patients whose Decision Making choices are beyond the clinician’s personal (Suggested time allotment: 30 minutes) comfort zone? Have participants break into small groups (3-5 3) How, if at all, is a woman’s choice to have an participants) and read the six descriptions. Ask abortion for reasons a health care provider the groups to discuss and reach consensus might not agree with different from a about which two women they will “assign” to woman or man’s choice to make other each of the three pregnancy options (adoption, medically related choices, such as smoking or abortion, parenting). After 20 minutes, have riding a motorcycle without a helmet, which the groups report back the decisions they made a health care provider might not agree with? and the reasons for their decisions. Allow each group to report their decisions without Part 2 interruption and then open discussion up. (Suggested time allotment: 45 minutes) Additional discussion questions: Ask participants to rank their choices in writing. Then read the list of women aloud 1) How did it feel to have to make these asking how many people ranked each woman decisions as a group? as their first choice by having those who chose 2) Which cases, if any, were fairly easy to raise their hands. Ask for someone who chose assign? Why? #1 to make the case for her; then for each of 3) Which cases were most difficult? Why? the other women, have someone who chose her make the case. Ask participants not to discuss Exercise C-5: Parenting and Adoption: or argue while the cases are being presented. Examining our Potential Biases How did you refute the arguments made for (Suggested time allotment 25 minutes) the women you did not choose? Label one end of the room “Very Comfortable” Discussion questions: and the other end of the room “Very Uncomfortable” and explain that the line 1) How did having to choose make you feel? between those two extremes represents a 2) Why is it so difficult to make these kinds of continuum. Read the descriptions of 2-3 of the choices? “Choosing to Parent” cases one at a time and 3) How could you avoid ever having to make ask participants to go to the spot along the choices of that sort in your practice? continuum that corresponds to the first emotional response they have to each description. Have one or two people from each spot share with the group their reasons for so choosing. After all stations have reported back

to the full group their reasons, participants can reasons while others in the group just listen. change stations if they have changed their Afterward, open it up to general discussion so choice. Repeat with 2-3 of the “Choosing participants can respond to the ideas which Adoption” scenarios. were expressed. Additional discussion questions: Additional discussion questions: 1) If you had to choose one or the other, were 1) What is your reaction to this question? you generally more comfortable with the 2) What other medical services might a health parenting scenarios or with the adoptions care provider “opt out” of providing? scenarios? Why? 3) What are some of the ways that a health 2) For those who had a change in comfort level care provider can reconcile personal beliefs after listening to others, what made you feel with a patient’s needs and beliefs? differently? 4) What is the difference, if any, for denying medical services for medical reasons vs. Exercise D-1: Views about the Role of personal reasons? the Health Care Provider (Suggested time allotment: 20 minutes) EXERCISE D-3: The Decision to Provide Have participants break down into small Abortion Care: Motivations and groups (4-5 participants) and read the excerpt. Obstacles to Practice Ask participants to work on the discussion (Suggested time allotment: 45 minutes) questions which follow in their small groups. Have participants complete Part 1 and Part 2 Have smaller groups report back to the group individually. Then have participants work in as a whole the most compelling or controversial groups of two to three people and discuss their issue this excerpt elicited in their small group answers. Smaller groups should report back to discussions. the larger group for further discussion one or No additional discussion questions. two issues which were especially compelling or controversial in their small group discussions. EXERCISE D-2: Personal Assessment of Suggestions for discussion questions for each Professional Obligations questionnaire are listed below. (Suggested time allotment: 45 minutes) Ask participants to consider the scale and Overall discussion question: The purpose of decide which position best represents their these particular exercises is to have you view. Then, have them cluster in different parts critically assess whether or not to be trained of the room according to the position they have and ultimately provide abortion services. You chosen and discuss briefly their reasons for have a greater responsibility to assess your their choice with others in their cluster. Then feelings about abortion and providing abortion ask individuals from each cluster to offer their than people in other professions since, as a

health care professional, you will ultimately be EXERCISE D-4: Obstacles to Providing the one to make or not make safe abortion Abortion Care: A Self-Evaluation services available. What are your thoughts (Suggested time allotment: 45 minutes) about this statement? Have participants complete the questionnaire Discussion questions for Part 1: individually. Then work on one barrier at a 1) Which reasons for providing abortions are time, asking participants to indicate which most compelling? suggestions might enable them to overcome that difficulty. 2) What makes them compelling? Additional discussion questions: 3) Which reasons might a health care provider find more compelling than a lay person? (i.e. 1) Which reasons for choosing not to provide In what ways has your professional education abortions can most easily be dealt with and and training influenced your beliefs?) overcome? Why? 4) What is the importance, if any, of 2) Which reasons seem most difficult to deal communicating the health care provider’s with or overcome? Why? perspective to the public? 3) How realistic are the suggestions for overcoming the reasons for choosing not to Discussion questions for Part 2: provide abortion? 1) Which reasons for not providing abortions 4) Are there other suggestions not included in are most compelling? the lists that might be helpful? 2) What makes them compelling? 5) What would make it easier to overcome the 3) Which reasons might a health care provider barriers to providing abortions? find more compelling than a lay person? (i.e. 6) What would make it harder? In what ways has your professional education and training influenced your beliefs?) Suggested References about 4) What is the importance, if any, of Facilitating Group Discussions communicating the health care provider’s Beresford T. How To Be a Trainer. Baltimore, MD: Planned Parenthood of Maryland, 1980. perspective to the public? Boyer RP with McCormick S. Helping People 5) What other medical services might you “opt Learn about Sexuality. Bristol, PA: Planned out” of providing? For what reasons? Parenthood of Bucks County. 6) If there are other services which you might Cook AT, Kirby D, Wilson P, and Atler J. Sexuality Education: A Guide to Developing and opt out of providing, how are these similar or Implementing Programs. Santa Cruz, CA: different from abortion? If you would not Network Publications, 1984. “opt out” of any other service, what about Silberman M, Auerbach C, and Silberman ML. abortion makes it different from other Active Training: A Handbook of Techniques, medical services? Designs, Case Examples, and Tips. San Francisco, CA: Jossey-Bass Inc. Publishers, 1997.