Reproductive and Sexual Health Handbook

There are many terms used to describe a pregnancy that may not have been intended or planned, including ‘unintended pregnancy’, ‘unplanned pregnancy’, ‘unexpected pregnancy’ and ‘mistimed pregnancy’.

Some women and their partner will carefully ‘plan’ a pregnancy, checking immunisation status, taking preconception supplements and maintaining a healthy lifestyle (e.g. decreasing alcohol consumption, ceasing smoking and other drugs, and maintaining a healthy weight). These are truly ‘planned pregnancies’. However, many pregnancies are intended but not planned.

The term ‘unintended pregnancy’ better reflects the situation where a pregnancy was neither planned nor intended. However it is important to note that many unintended pregnancies continue to become a wanted pregnancy.

A proportion of women are faced with a ‘crisis’ pregnancy. This has been defined as ‘a pregnancy which is neither planned nor desired by the woman concerned, and which represents a personal crisis for her’.⁽¹⁾

Unintended pregnancy has been associated with adverse maternal and infant health outcomes⁽²⁾ and limits opportunities to participate in preconception health promotion.⁽³⁾ Control over pregnancy intention is also an important means to minimise the need for abortion. An audit of 3,018 medical records of Victoria’s largest public pregnancy advisory service (PAS) showed that the primary

Obtaining accurate data regarding the prevalence and risk factors for unintended pregnancy is challenging, however several studies have endeavoured to do this.

A national population telephone survey was conducted in 2015 which asked 2,013 women, aged between 18-45 years, whether they had experienced an unintended pregnancy within the last 10 years and the outcome of all pregnancies.⁽⁵⁾ Of these women, 69% reported a pregnancy within the last 10 years; 26% had fallen pregnant without intending to do so; 53% of unintended pregnancies resulted in a live birth and 30.4% of unintended pregnancies ended in abortion. A 2006 Australian survey of 2,000 women found 51% of the respondents reported having experienced an ‘unplanned pregnancy’ in their lifetime. In the survey, 49% of women continued the pregnancy, 31% had an abortion, 18% miscarried and 2% adopted out.⁽⁶⁾ Understanding the socio-demographic risk and protective factors associated with unintended pregnancy is important to guide clinical and public health strategies to help reduce unintended pregnancy rates. A national population‐based survey of women and men aged 18–51 years, recruited from a random sample from the Australian Electoral Roll was conducted in 2013.⁽⁷⁾ Data from 2,235 completed questionnaires were analysed

Studies examining pregnancy decision-making and timing have found that most women made their decision about the outcome of the pregnancy immediately upon discovering they were pregnant and acted on their decision very quickly.^{(13, 14)} This appeared to be true both for those who chose to continue their pregnancy and keep their baby and those who chose to terminate the pregnancy.

A urine beta human chorionic gonadotrophin (hCG) test has often already been done by the patient at home before they present to a clinician, but it is important to offer to repeat this test. It can be useful to sensitively ask how they would feel about a positive result while you wait for the result of the pregnancy test. Do not make assumptions about the ‘wantedness’ of the pregnancy.

This can be a challenging consultation. While many patients will simply require information about their options, others may need more intense non-directive decision-making counselling. Other factors may complicate the decision-making process such as financial difficulties, relationship problems or domestic violence.

Some key strategies for clinicians include:

provide a supportive, non-judgmental setting allow time for the patient/couple to express their immediate feelings allow the patient/couple to choose immediate discussion, or to “let it sink in” and return at a later date provide resources (see resources)

Non-directive decision-making counselling is a patient-centred approach that focuses on the patient exploring the outcome which will be best for them. It is important to be able to discuss all available options and provide information and resources to support decision-making. This might include referral information and decision-making tools such as the Ottawa personal decision guide, available in the resource box below.

Non-directive pregnancy support counselling is supported by a specific Medicare item number that can be claimed by clinicians (including GPs and other health professionals on referral from a GP such as mental health nurses, psychologists and social workers) who have done an accredited training course in non-directive pregnancy support counselling for patients who are pregnant or have had a pregnancy

If a patient is considering or decides to continue an unintended pregnancy it is important that appropriate antenatal care is arranged as soon as possible (see Pregnancy and antenatal care in Chapter 9: Preconception Care and Pregnancy). There may also be financial concerns and they may be eligible for government support in raising a child. Information is available from the responsible government agency. Referral to a social worker may be appropriate.

Adoption is the legal process that permanently transfers all the legal rights and responsibilities of being a parent from the child’s birth parents to the adoptive parents. A new birth certificate is issued. In NSW, Family and Community Services is the government agency responsible for the provision of adoption services and they work with birth parents considering adoption for their child and families who wish to adopt. There is a counselling process and post adoption services. Each state and territory has a similar agency.

Both the birth parents must consent to the child’s adoption although there is a legal process to dispense with the mother or father’s consent in certain circumstances. Parents must wait at least 30 days after the child is born before they can sign the consent to adoption. There is then a further 30 days revocation period in which they can change their minds. The birth parents can maintain contact with the child through an adoption plan agreed with the adopting parents.

Today all adopted children have the legal right to know about their origins from time of placement. An adoption caseworker works with the birth parents and the adoptive parents to form an adoption plan that outlines the agreed

Foster care involves a child being looked after by someone else with government support. There are different types of foster care including:

Temporary Foster Care: This can be used while the birth parent/s resolve accommodation, financial or personal problems. During voluntary care (i.e. not ordered by the Court) the birth parent/s remain the child’s guardian and can see the child. Temporary care is usually limited to several weeks. Long Term Foster Care: If a child is in long-term foster care, the birth parents lose legal guardianship and/or custody, but remain the child’s legal parent/s. The Court might not agree it is in the child’s best interests to be returned to the birth parent/s even if they request this.

More information about adoption and fostering

Adoption and Permanent Care Services on 02 9716 3003 or email: adoption@community.nsw.gov.au. Adoption process and alternative, see Community & Family Services website. Adoption and the agencies responsible in other states, see Children by Choice website.

Abortion is lawful in every state and territory in Australia, although the exact laws regarding gestational limit and consent process vary so it is important to be familiar with the local legal framework if providing abortion services (see Abortion in Chapter 19: Legal Considerations in Reproductive and Sexual Health). Providing information regarding abortion and arranging referral to a provider is considered part of usual health care in Australia and well within the scope of general practice and other health services.

Surgical abortion involves inserting a small plastic tube through the cervix to remove the lining and contents of the uterus by applying suction. Most surgical abortions are performed under IV sedation or ‘twilight sleep’. There may also be the option of having a local anaesthetic only or a general anaesthetic, depending on the setting.

There are two recommended methods for first trimester surgical termination of pregnancy; electric vacuum aspiration (EVA) and manual vacuum aspiration (MVA). Dilatation and curettage is no longer recommended for abortion.⁽¹⁵⁾

Electric vacuum aspiration (EVA) is commonly used for termination of pregnancy in the first trimester up to 14 weeks. At 12-14 weeks larger tubing and forceps may also be required. Manual vacuum aspiration (MVA) can be used in the first trimester; some providers recommend it only to 10 weeks. It is useful for procedures done under local anaesthetic as it is quieter and may be less painful.⁽¹⁶⁾ MVA is widely used in low resource settings as it is economical.

Surgical abortion is often delayed until 6 weeks gestation due to the risk of missing a very tiny early pregnancy when evacuating the uterine contents.

Cervical ripening agents, such as misoprostol, may be used orally or

There are different protocols for medical abortion throughout the world, but in Australia the accepted regimen is a two-stage process:

A single tablet of mifepristone 200mg is first taken orally. This is a progesterone receptor antagonist and blocks progesterone needed to maintain the pregnancy. This is followed by self-administration of 4 x 200mcg misoprostol tablets taken 36-48 hours later. Misoprostol is a synthetic analogue of prostaglandin E1 which causes uterine contractions to expel the contents of the uterus.

For more information about the characteristics of surgical abortion, see Table 10.1.

It is normal to experience an emotional response to terminating a pregnancy. Most women report feeling a range of emotions including relief, sadness and guilt. Current evidence suggests that for a woman experiencing an unwanted pregnancy, mental health is largely unaffected whether she chooses to have an abortion or continue to birth.(30-33) A woman seeking pregnancy termination can best be supported by health services through appropriate, individualised, responsive care, including the provision of accurate information about mental health and treatment access if required.⁽³⁰⁾

It is important to actively respond to any patients reporting ongoing distress, and referral to a psychologist or social worker may be appropriate. There is a specific Medicare item number for pregnancy support counselling relating to a pregnancy within the last 12 months, regardless of the outcome of that pregnancy.⁽³⁴⁾

Fertility can return within a week post abortion. Patients are advised not to have sex for 7 days after MTOP to minimise the risk of infection.

An important part of the MTOP consultation and follow up is to ensure adequate and timely initiation of contraception.

Providing the patient is medically eligible according to the UK Medical Eligibility Criteria (MEC), most methods of contraception (with the exception of the hormonal or copper IUD) can be started either at the time of, or soon after, MTOP.⁽³⁵⁾

If the combined Pill, POP, depot medroxyprogesterone acetate (DMPA), vaginal ring or implant is commenced within 5 days of the MTOP, pregnancy can be excluded and they will be effective immediately.

There is a concern with regard to commencing DMPA at the time of the MTOP and impairment of the progesterone blocking action of mifepristone and subsequent reduction in efficacy of the mifepristone. This needs to be considered on a case by case basis. The potentially higher risk of failed medical termination with concurrent DMPA use should be discussed with women, and appropriate follow-up should be arranged. Nevertheless, DMPA can also be a useful bridging method until an IUD is inserted.⁽³⁶⁾

Insertion of an IUD should be delayed until completion of

Family Planning Australia fact sheets:

Unintended Pregnancy: Abortion Unintended pregnancy: Continuing a pregnancy Pregnant? Working Through Your Options – this resource includes unbiased information on all options as well as referral information and useful decision-making tools

Australian Contraception and Abortion Primary Care Practitioner Support Network (AusCAPPS): https://medcast.com.au/communities/auscapps. AusCAPPS is an NHMRC-funded online community of practice developed in partnership with the RACGP, RANZCOG, APNA, the PSA, and other key stakeholders for primary health care providers who are interested in increasing women’s access to long acting reversible contraceptives (LARC) and medical abortion. GPs, practice nurses and pharmacists are invited to join at no cost.

Pregnancy, Birth and Baby: Pregnancy, Birth and Baby (or call: 1800 882 436) is an initiative of the federal government, this resource offers information and support to women and their partners through pregnancy, birth and the first 5 years. This service will offer unbiased counselling and referral information for those considering terminating a pregnancy but the majority of the information on the website caters for those continuing a pregnancy.

Children by Choice: Children By Choice is a Brisbane-based non-profit organisation, committed to providing unbiased information on all unintended pregnancy options.

RANZCOG

 The Use of Mifepristone for medical abortion – O’Keeffe S. Crisis Pregnancy and Pregnancy Decision Making: An Outline of Influencing Factors. Report No. 1. [Internet]: Crisis Pregnancy Agency; 2004. Available from: https://www.sexualwellbeing.ie/for-professionals/research/research-reports/crisis-pregnancy-and-pregnancy-decision-making-an-outline-of-influncing-factors.pdf. Gipson J, Koenig MA, Hindin MJ. The effects of unintended pregnancy on infant, child, and parental health: A review of the literature. Stud Fam Plann. 2008;39:18-38. Whitworth M, Dowswell T. Routine pre‐pregnancy health promotion for improving pregnancy outcomes (Cochrane Review). The Cochrane Database of Systematic Reviews. 2009;Oct 7(4):CD007536. Rowe H, Kirkman M, Hardiman EA, Mallett S, Rosenthal DA. Considering abortion: a 12-month audit of records of women contacting a Pregnancy Advisory Service. MJA. 2009;190(2):69-72. Taft A, Shankar , Black KI, Mazza D, Hussainy S, Lucke JC. Unintended and unwanted pregnancy in Australia: a cross-sectional, national random telephone survey of prevalence and outcomes. MJA. 2018;209(9):407-8. Marie Stopes International. Real Choices: Women, contraception and unplanned pregnancy. [Internet]. Marie Stopes International; 2008. Rowe H, Holton S, Kirkman M, Bayly C, Jordan L, McNamee K, et al. Prevalence and distribution of unintended pregnancy: the Understanding Fertility Management in Australia National Survey. Aust N Z J Public Health. 2016 Apr;40(2):104-9. Grayson N, Hargreaves J, Sullivan EA. Use of routinely collected national data sets for reporting induced abortion in Australia. Report