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In the late 1980s NAF began to hear from our member clinics that they were having trouble locating physicians to work on a full- or part-time basis providing abortion care. The volume of these reports grew, substantiating our fears that we were witnessing more than a local or short-term phenomenon.

In response, in the fall of 1990 NAF convened a national symposium, co-sponsored by the American College of Obstetricians and Gynecologists (ACOG), to explore the emerging crisis in abortion service delivery. The goal of the symposium was to identify the key issues and problems behind the abortion provider shortage and to delineate strategies to ameliorate the problem. Attendees included physicians, physician assistants, administrators, teachers, researchers, and representatives from ACOG, the Accreditation Council of Graduate Medical Education (ACGME), and the Council on Resident Education in Obstetrics & Gynecology (CREOG).

The conclusions and recommendations from this symposium were reported by NAF in Who Will Provide Abortion? Ensuring the Availability of Qualified Practitioners (order a copy). One of the key problems identified was a lack of training in residency programs for new physicians.

Policy recommendations for increasing the number of physicians trained to provide abortions focused both on residency programs and clinic work settings. Symposium participants suggested that abortion would only be regularly available when it was finally routinely included in all obstetrics-gynecology residency programs as a standard part of training. Outpatient abortion facilities were encouraged to establish formal linkages with residency training programs and to create incentives, such as research and compensation opportunities, for residents to train at community-based outpatient facilities.

To aid in the integration of abortion training in residency programs and clinics, NAF developed a Clinical Training Curriculum in Abortion Practice in 1995. In 2005, NAF updated the curriculum to include new data and current practices, as well as techniques of manual vacuum aspiration and medical abortion.

Clinical Training Curriculum in Abortion Practice, 2nd Edition

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Module 1 - Pregnancy Verification and Estimation of Gestational Age

Errors in the evaluation of pregnancy duration are one important cause of abortion complications. Understanding the use of human chorionic gonadotropin (hCG) tests and diagnostic ultrasound, both independently and in combination, is essential for the accurate estimation of gestational age and for the evaluation of pregnancy location and integrity. In this and other modules, gestational age is computed by menstrual dates (weeks since the start of the last menstrual period), rather than conception dates (weeks since fertilization).

Module 2 - Counseling and Informed Consent

This section provides an overview of approaches used for counseling patients seeking abortions and for obtaining informed consent. It is written with the understanding that counseling is a developed skill that requires a certain level of training and experience. The techniques for and content of pregnancy-options counseling and pre-abortion counseling are somewhat different subjects that require unique skills. In many cases, the trainee may not routinely provide counseling on pregnancy options to the patient and thus may not be required to develop special skills in this area. However, the trainee should be familiar with the content of pregnancy options counseling and must be familiar with pre-abortion counseling as well as the special considerations that apply in obtaining informed consent for abortion.

Module 3 - Selection of Appropriate Procedure

This section provides an overview of the various methods of abortion. It describes when each is generally employed and the settings in which each may be medically appropriate. Induction techniques of mid-trimester abortion are covered in some detail in this section, because they are not included elsewhere in the curriculum. This module is not intended to dictate an exclusive course of management. Variations in patient needs and available resources may justify alternative approaches.

Module 4 - Medical Abortion Screening, Regimens, Management & Follow-up

Medical abortion presents another option for early pregnancy termination. Some women will prefer this method because it enables them to avoid instrumentation; or because they perceive it to be more "natural," easier, or better in some other way than vacuum aspiration; or because part of the abortion process can occur outside a medical setting. Mifepristone/misoprostol regimens and methotrexate/misoprostol have been extensively studied and are documented to be safe and effective for first-trimester terminations to 63 days and 49-56 days gestation (also referred to as LMP), respectively. Due to the wide availability of highly sensitive urine pregnancy tests, early presentation for pregnancy termination occurs with greater frequency and medical abortion presents one therapeutic option. The provider must understand who is a candidate for medical abortion, how to counsel and adequately prepare patients for the medical abortion process, and the contraindications to medical abortion. Additionally, the provider must be facile with methods for accurately dating gestational age, familiar with the medications used and dosing regimens, and able to recognize and treat complications associated with medical abortion. (Note: In this curriculum, medical abortion refers to methods employed in the 1st trimester, primarily through 63 days gestation. We use "induction abortion" for drug-based methods employed during or after the second trimester).

Module 5 - Medical Screening

Screening for underlying medical or gynecological problems, coupled with appropriate management when such problems are detected, can significantly decrease the risk of many abortion complications and avoid exacerbation of the underlying conditions. Pre-procedure detection of reproductive tract anatomic variations and consequent modifications in surgical technique or in some cases use of a medical abortion method may result in a procedure that is safer and better tolerated. To decrease post-abortion infectious morbidity, all patients should receive antibiotics at the time of surgical abortion. Preoperative antibiotic treatment (i.e. therapeutic doses) for selected patients should be considered. Note: Although there are areas of overlap, this module focuses on medical screening for vacuum aspiration and D&E. Information about medical screening prior to a medical abortion is covered in detail in Module 4.

Module 6 - Pain Control

Relief of pain and control of anxiety are important determinants of abortion safety as well as patient satisfaction. Ideally, the woman should be offered her choice of several pain management options. Women undergoing aspiration abortion in the first trimester commonly choose local anesthesia with or without intravenous pain medications. According to a survey of NAF clinics, the most common method of pain management in first-trimester vacuum aspiration was local anesthesia, with or without oral pre-medication (58% of respondents), and the second most common method was local anesthesia combined with IV sedation (32% of respondents). Surgical abortions in the second trimester are commonly provided using more pain medications compared to those done in the first trimester; typically, women undergoing D&E procedures receive intravenous analgesics and anxiolytics. The clinician should be able to provide abortions using gentle operative technique as well as verbal support in order to minimize patient discomfort. In addition, the clinician should understand the pharmacology of any analgesic and anxiolytic used, and should be able to recognize and manage adverse effects of these drugs. This module will review how to provide a paracervical block, an essential skill in first-trimester abortion. Note: This module focuses on pain control for vacuum aspiration and D&E techniques. Specific information about pain relief in medical abortion is included in Module 4.

Module 7 - Vacuum Aspiration and D&E Technique

This section contains specific information on both vacuum aspiration and dilation and evacuation (D&E) procedures. However, it must be pointed out to the trainee that each technique presented is but one way of providing an abortion, and that many other approaches or adaptations are acceptable. Some information presented reflects updates in clinical knowledge and the evidence to support such change in practice as referenced. General reference texts follow specific references at the end of this module.

Module 8 - Management of Abortion Complications

Sound surgical skills are important for preventing abortion compli¬cations, but knowing how to manage complications is also essential. The Accreditation Council for Graduate Medical Education (ACGME) standards for U.S. ob-gyn residency programs require that "experience with management of complications of abortion must be provided to all residents." Thus, all ob-gyn residents, including those who opt out of abortion training, should participate in management of complications. Note: This module focuses primarily on complications related to vacuum aspiration and D&E techniques. Specific information about management of complications in medical abortion is included in Module 4.

Module 9 - Post-Abortion Care and Follow-up

This section introduces the trainee to the essentials of post-abortion care and follow-up. The service you actually provide will depend on care protocols in your specific site. In many high-volume sites, non-physician staff take the first call (phone coverage) and see patients for routine follow-up visits. Note: Although there are areas of overlap, this module focuses primarily on post-abortion care and follow-up after vacuum aspiration and D&E. Information about post-abortion care and follow-up for medical abortion is covered in detail in Module 4.

Module 10 - Evaluation

Without a format for evaluation, the results of training cannot be effectively realized. In the short term, an evaluation strategy provides the training program with immediate data on the competency of trainees. In the long term, an evaluation mechanism provides feedback on whether the methods are working and whether the most setting-appropriate training is being provided.

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Supplemental Module - The Abortion Option: A Values Clarification Guide for Health Professionals

In spite of our efforts at objectivity, we all hold personal values that can influence how we respond to our patients. Sometimes these values are very clear to us and are easily articulated. Others exist at a deeper level, so that we don't necessarily recognize the influence they have on our behavior and judgments as health care professionals. Further, one's values may change in response to life experiences and your encounters with patients and colleagues may influence your beliefs without your having much of a chance to reflect on these changes. This resource (PDF file, 2.4 MB; version for black and white printers, 1.3 MB) is intended to help you clarify your personal values about pregnancy options and abortion, and to help you think about those values in the context of professional judgments you may be called upon to make. This guide can be used by individuals or groups, and is appropriate for the wide range of health care professionals who provide care to women experiencing unintended pregnancies.

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Supplemental Module - NAF's Clinical Policy Guidelines

NAF's Clinical Policy Guidelines (CPGs), the only evidence-based guidelines for abortion practice in North America, provide a basis for ongoing quality assurance in abortion care. The guidelines are developed based on rigorous review of the relevant medical literature and known patient outcomes.

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Principles of Abortion Care: A Curriculum for Physician Assistants and Advanced Practice Nurses, Edited by Michael S. Policar, MD, MPH, Amy E. Pollack, MD, MPH, Cate Nicholas, MS, PA, and Sudan Dudley, PhD

This 1999 curriculum includes 11 modules on all aspects abortion care in outline form that is appropriate for didactic and/or clinical training. More

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Medical Abortion Curriculum Resources

NAF has developed a complete series of medical abortion curriculum resources, including educational slide modules, self-study guides, online programs, and other professional educational materials. More

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