Lisa H. Harris

Risk and the Pregnant Body

November-December 2009 The first trimester of pregnancy had not been an easy one for Andrea—mornings brought waves of nausea and vomiting, and afternoons, debilitating fatigue.1 What got her through were two things: the hope that her symptoms would start to lift when she got past her first trimester, and, of course, the promise of a baby in December. Unfortunately, neither of these came to pass. Andrea had just reached fifteen weeks’ gestation when she arrived in the emergency room at a major academic medical center. After a short week of relief, her nausea had returned, accompanied by a lowgrade, persistent, gnawing abdominal pain, and— perhaps of more concern—a conviction that something was badly wrong. Given the signs, her attending obstetrician ordered a CT scan, the gold standard for ruling out what would be inexcusable to miss: appendicitis. Yet the medical imaging team, nervous about radiation exposure with a pregnant patient, resisted the CT scan. First they attempted to image without radiation, but an ultrasound and an MRI yielded no useful information. The team then requested extra layers of documentation verifying that risks of radiation exposure to the fetus were discussed with the Reasoning well about risk is most challenging when a woman is pregnant, for patient and doctor

Dynamics of stigma in abortion work: Findings from a pilot study of the Providers Share Workshop

Abortion is highly stigmatized in the United States. The consequences of stigma for abortion providers are not well understood, nor are there published accounts of tools to assess or alleviate its burdens. We designed The Providers Share Workshop to address this gap. Providers Share is a six-session workshop in which abortion providers meet to discuss their experiences, guided by an experienced facilitator. Seventeen workers at one US abortion clinic participated in a pilot workshop. Sessions were recorded and transcribed, and an iterative process was used to identify major themes. Participants highlighted stigma, located in cultural discourse, law, politics, communities, institutions (including the abortion clinic itself), and relationships with family, friends and patients. All faced decisions about disclosure of abortion work. Some chose silence, fearing judgment and violence, while others chose disclosure to maintain psychological consistency and be a resource to others. Either approach led to painful interpersonal disconnections. Speaking in the safe space of the Workshop fostered interpersonal connections, and appeared to serve as an effective stigma management tool. Participants reflected favorably upon the experience. We conclude that the Providers Share Workshop may alleviate some of the burdens of abortion stigma, and may be an important intervention in abortion human resources. We present a conceptual model of the dynamics of stigma in abortion work.

Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure.

OBJECTIVE: To examine patient treatment preferences and satisfaction with an office-based procedure for early pregnancy failure and to compare resource use and cost between office and operating room management of early pregnancy failure. METHODS: This study was a prospective observational study of 165 women presenting for surgical management of early pregnancy failure. Participants completed a preoperative questionnaire addressing treatment preferences and expectations and a postoperative questionnaire measuring level of pain experienced and satisfaction with care. Resource use was determined by measuring the time patients spent at the health care facility and the actual procedure time. Cost was estimated using an institutional database. RESULTS: One hundred fifteen women from the office and 50 from the operating room were enrolled. Patients selecting outpatient management scored “privacy,” “avoiding going to sleep,” and “previous experience” higher than the operating room group (P < .05). Patients who perceived that their physicians preferred one procedure over the other were more likely to select that procedure (P < .001). Satisfaction was high in both groups, and underestimating the procedures discomfort was negatively associated with satisfaction (P < .002). Costs were greater than two-fold higher in the operating room group compared with the office group (P < .01). Complications were uncommon, but hemorrhage-related complications were four times more common in the operating room group than in the office group (P < .01). CONCLUSION: Office-based surgical management of early pregnancy failure is an acceptable option for many women and offers substantial resource and cost savings. LEVEL OF EVIDENCE: II-2

The Class A Scavenger Receptor, Macrophage Receptor with Collagenous Structure, Is the Major Phagocytic Receptor for Clostridium sordellii Expressed by Human Decidual Macrophages

Clostridium sordellii is an emerging pathogen associated with highly lethal female reproductive tract infections following childbirth, abortion, or cervical instrumentation. Gaps in our understanding of the pathogenesis of C. sordellii infections present major challenges to the development of better preventive and therapeutic strategies against this problem. We sought to determine the mechanisms whereby uterine decidual macrophages phagocytose this bacterium and tested the hypothesis that human decidual macrophages use class A scavenger receptors to internalize unopsonized C. sordellii. In vitro phagocytosis assays with human decidual macrophages incubated with pharmacological inhibitors of class A scavenger receptors (fucoidan, polyinosinic acid, and dextran sulfate) revealed a role for these receptors in C. sordellii phagocytosis. Soluble macrophage receptor with collagenous structure (MARCO) receptor prevented C. sordellii internalization, suggesting that MARCO is an important class A scavenger receptor in decidual macrophage phagocytosis of this microbe. Peritoneal macrophages from MARCO-deficient mice, but not wild-type or scavenger receptor AI/II–deficient mice, showed impaired C. sordellii phagocytosis. MARCO-null mice were more susceptible to death from C. sordellii uterine infection than wild-type mice and exhibited impaired clearance of this bacterium from the infected uterus. Thus, MARCO is an important phagocytic receptor used by human and mouse macrophages to clear C. sordellii from the infected uterus.

Rethinking maternal-fetal conflict : Gender and equality in perinatal ethics

Practitioners who care for pregnant women face dilemmas when their patients use illicit drugs, reject medical recommendations, or cause fetal harm. Many ethics scholars characterize those situations as maternal-fetal conflicts. In conflict-based models, maternal rights are considered to conflict with fetal rights, or moral obligations owed to pregnant women are considered to conflict with those owed to their fetuses. I offer an alternative model of pregnancy ethics by applying relational and equality-based moral theories to situations of fetal harm by pregnant women. In this model, clinicians faced with ethical dilemmas should attempt to understand pregnant women and their decisions within their broad social networks and communities, ask how the clinicians personal standpoint influences outcomes judged to be ethical, and determine whether the clinicians ethical formulations reduce or enhance existing gender, class, or racial inequality. This model focuses on the mutual needs of pregnant women and fetuses rather than on their mutually exclusive needs. It also avoids many pitfalls of traditional ethical formulations, specifically their tendency to neglect gender-specific modes of moral reasoning, their implicit assumptions that application of universal principles like autonomy and beneficence results in objective ethical solutions, and their failure to account for the ways that projecting fetal needs perpetuates social inequalities. This model provides the ethical foundations for moving law and policy away from criminalization and toward prevention of prenatal harm.

Recognizing Conscience in Abortion Provision

The exercise of conscience in health care is generally considered synonymous with refusal to participate in contested medical services, especially abortion. This depiction neglects the fact that the provision of abortion care is also conscience-based.

Confronting the challenge of unsafe second-trimester abortion

Unsafe abortion accounts for approximately 13% of maternal deaths worldwide—roughly 47 000 deaths per year. Most deaths from unsafe abortion occur in low‐resource countries. Second‐trimester abortion carries a higher risk of morbidity and mortality compared with first‐trimester abortion and, although the former comprises the minority of abortion procedures worldwide, it is responsible for the majority of serious complications and death where unsafe abortion is prevalent. Therefore, improving access to safe second‐trimester abortion must be a priority in low‐income regions of the world if the majority of deaths from unsafe abortion are to be prevented. In the present paper, we consider a variety of barriers to second‐trimester care, including healthcare provider training and abortion stigma, which may lead to neglect of unmet need for second‐trimester services.

Second Trimester Abortion Provision: Breaking the Silence and Changing the Discourse

Abstract How do abortion providers determine how late in pregnancy they will provide abortion services? While law, training and socio-political factors likely play a part, this essay considers additional factors, including: personal and psychological aspects, visceral responses to the fetus and fetal parts at later gestations, feelings that second trimester abortion is violent, and ethical concerns with second trimester abortion. Providers may censor themselves with respect to these issues, fearing that honest acknowledgement of difficult aspects may be dangerous to the pro-choice movement; that is, such acknowledgements could appear to legitimise the anti-abortion stance that second trimester abortion is gruesome and morally unacceptable. I argue that this silence is harmful to providers, the pro-choice movement and the women who need abortion services. I make the case for pro-choice discourse that is honest about the nature of abortion procedures and uses this honesty to strengthen abortion care, including second trimester abortion. Résumé Comment les soignants qui pratiquent les avortements déterminent-ils jusqu’à quel stade ils accepteront d’interrompre une grossesse? Si la législation, la formation et les facteurs sociopolitiques jouent probablement un rôle, cet essai envisage d’autres facteurs, notamment de nature personnelle et psychologique, des réactions viscérales au fétus et aux parties fétales dans les gestations avancées, le sentiment que l’avortement du deuxième trimestre est violent, et les préoccupations éthiques qu’il suscite. Les soignants peuvent s’autocensurer car ils craignent qu’une prise en compte honnête de ces questions difficiles ne soit dangereuse pour le mouvement en faveur du libre choix, c’est-à-dire que cette reconnaissance paraisse légitimer le discours anti-avortement selon lequel l’avortement du deuxième trimestre est horrible et moralement inacceptable. J’estime que ce silence gêne les soignants, le mouvement pour le libre choix et les femmes qui souhaitent avorter. Je préconise un discours pour le libre choix qui aborde honnêtement la nature des procédures d’avortement et utilise cette honnêteté pour renforcer les services d’avortement, y compris au deuxième trimestre. Resumen Cómo determinan los prestadores de servicios de aborto hasta qué semana de gestación proporcionan servicios de aborto? Aunque la ley, capacitación y factores sociopolíticos probablemente influyen en esta decisión, en este ensayo se consideran otros factores, como los aspectos personales y psicológicos, respuestas viscerales al feto y las partes fetales en gestaciones más avanzadas, creencias de que el aborto en el segundo trimestre es violento e inquietudes éticas respecto al mismo. Algunos prestadores de servicios se censuran al respecto, temiendo que el reconocer abiertamente los aspectos difíciles podría ser peligroso para el movimiento pro libre elección: por ejemplo, afirmar que el aborto en el segundo trimestre es horripilante y moralmente inaceptable, podría interpretarse como una forma de legitimar la postura contra el aborto. Sostengo que este silencio es perjudicial para los prestadores de servicios, el movimiento pro libre elección y las mujeres que necesitan servicios de aborto. Expongo los argumentos a favor de un discurso pro libre elección, que sea sincero respecto a la naturaleza de los procedimientos de aborto y utilice esta sinceridad para fortalecer los servicios de aborto, incluidos los del segundo trimestre.

Counseling women with early pregnancy failure: Utilizing evidence, preserving preference

OBJECTIVES To apply principles of shared decision-making to EPF management counseling. To present a patient treatment priority checklist developed from review of available literature on patient priorities for EPF management. METHODS Review of evidence for patient preferences; personal, emotional, physical and clinical factors that may influence patient priorities for EPF management; and the clinical factors, resources, and provider bias that may influence current practice. RESULTS Women have strong and diverse preferences for EPF management and report higher satisfaction when treated according to these preferences. However, estimates of actual treatment patterns suggest that current practice does not reflect the evidence for safety and acceptability of all options, or patient preferences. Multiple practice barriers and biases exist that may be influencing provider counseling about options for EPF management. CONCLUSION Choosing management for EPF is a preference-sensitive decision. A patient-centered approach to EPF management should incorporate counseling about all treatment options. PRACTICE IMPLICATIONS Providers can integrate a counseling model into EPF management practice that utilizes principles of shared decision-making and an organized method for eliciting patient preferences, priorities, and concerns about treatment options.

Abortion providers, stigma and professional quality of life.

OBJECTIVES The Providers Share Workshop (PSW) provides abortion providers safe space to discuss their work experiences. Our objectives were to assess changes in abortion stigma over time and explore how stigma is related to aspects of professional quality of life, including compassion satisfaction, burnout and compassion fatigue for providers participating in the workshops. STUDY DESIGN Seventy-nine providers were recruited to the PSW study. Surveys were completed prior to, immediately following and 1 year after the workshops. The outcome measures were the Abortion Provider Stigma Survey and the Professional Quality of Life (ProQOL) survey. Baseline ProQOL scores were compared to published averages using t tests. Changes in abortion stigma and aspects of professional quality of life were assessed by fitting a two-level random-effects model with repeated measures at level 1 (period-level) and static measures (e.g., demographic data) at level 2 (person-level). Potential covariates included age, parenting status, education, organizational tenure, job type and clinic type (stand-alone vs. hospital-based clinics). RESULTS Compared to other healthcare workers, abortion providers reported higher compassion satisfaction (t=2.65, p=.009) and lower burnout (t=5.13, p<.0001). Repeated-measures analysis revealed statistically significant decreases in stigma over time. Regression analysis identified abortion stigma as a significant predictor of lower compassion satisfaction, higher burnout and higher compassion fatigue. CONCLUSIONS Participants in PSW reported a reduction in abortion stigma over time. Further, stigma is an important predictor of compassion satisfaction, burnout and compassion fatigue, suggesting that interventions aimed at supporting the abortion providing workforce should likely assess abortion stigma. IMPLICATIONS Stigma is an important predictor of compassion satisfaction, burnout and compassion fatigue among abortion care providers. Therefore, strengthening human resources for abortion care requires stigma reduction efforts. Participants in the PSWs show reductions in stigma over time.