Termination of Pregnancy in Lothian

A Health Needs Assessment

Rosemary CochraneSubspecialty trainee

Chalmers Centre for Sexual and Reproductive HealthEdinburgh

November 2011

Aims

• describe the population accessing termination of pregnancy services in Lothian

• describe the current service in Lothian• identify areas where delay in service

provision exists and to recommend ways to decrease delay

• identify areas of unnecessary complexity in the patient’s journey through the service

Aims

• elicit stakeholders views - patients, staff and management

• consider evidence of effective intervention to improve termination services

• recommend potential interventions to improve the service for patients and staff, and to eliminate waste.

• support planning for change from 2011 onwards.

Total in Scotland 2010

=12386

•2254 were carried out in Lothian

•12.1 women per 1000 aged 15-44

•508 (25.2%) TOPs were in women <19 years

•31.8% were repeat TOP (Scotland 28.4%)

•In Depcat 1 16.9/1000 women

Abortion mapping – over 20 years

Terminations from Depcat 1-2:• 22.3 / 1000 in 2007• 16.9 / 1000 in 2010.

Current service in Lothian

• 2254 per year• Royal Infirmary of Edinburgh -

80%• St John’s Hospital, Livingston -

20%• 37% of Gynaecology budget• 70% before 9 weeks gestation• 78% are medical procedures• 55% of those at RIE are by EMD

Number of abortions by method at RIE 2005-2010

9881112 1147 1202

14321516

187142 138

146

136115

11231102 1047

1061 631 496

0

500

1000

1500

2000

2500

2005 2006 2007 2008 2009 2010

Year

Nu

mb

er

of

term

ina

tio

ns

STOP

MID

MTOP

Patient pathway

• primary care appointment→ referral to hospital→ hospital assessment clinic: counselled, ?DVD, ultrasound to establish gestation, consent, blood sample, urine for STI

screen→ plan made for next step→ if medical, may get 1st part same day→ contraceptive plan

• approximately 2 hour visit

Patient pathway

Key: REC = Reception D = Doctor’s room W/A = waiting area N1 = First nurse’s room T = toilet N2 = Second

nurse’s roomUS = Ultrasound room CSW = Clinical support

worker

REC W/A

US

T

N1 N2 D

CSW

N1 N2 D US

T

CSW

REC W/A

Service Standards

• HIS Standard 6: Termination of Pregnancy requires that women receive safe termination of pregnancy with minimal delay, followed by contraceptive advice and psychological support.

• 70% of TOP should be before 63 days gestation

• 60% of women should leave service with effective contraceptive plan

RCOG and FSRH Consensus Statement 2008

Delays in referral associated with • a lack of awareness of the possibility of

pregnancy • delays in diagnosis • access to and the availability of abortion services• negative attitudes of some referring practitioners • “In many services the patient journey from

suspicion of pregnancy to completion of the procedure can be overly complex, particularly in the patients' perception. This is even more pertinent for vulnerable members of the community for whom particular support

is needed to enable them to use the services more effectively.”

• A large minority of patients accessing TOP services within Lothian are either young people(<19 years) or from the most deprived areas of the region, for whom the complexity of the TOP journey may well lead to delay, dissatisfaction with, or even avoidance of the service.

The patient experience

• Women’s choices pragmatic, related to finite household and psychosocial resources

• Positive responses to, and outcomes from TOP, are associated with:

rapid access to services supportive non-judgemental staff home TOP good information and support

• Patients keep their experiences secret from family and friends - “The Silent Consumer”

1. Zapka et al 2001

Methodology

• Service users and service providers interviewed

• 17 staff members and 17 service users

• Staff– Doctors– Nurses– Receptionists– Sonographer– Clinical support workers– Managers

Results

Service user interviews:• 66 eligible patients• 17 agreed to take part• 17-34 years, mean age 24• 6/17 repeat TOP (cf 32% for Lothian)• 14 white UK• 3 non-UK

1 student 1 married to Scottish man 1 travelling to UK solely for purpose of obtaining TOP

Results: service users

• In general, women were very satisfied with the service they received

Theme/comment No. of replies/times mentioned

No questions unanswered and certain about next step

17

Friendly clinic staff 17

Positive attitude from GP/CY/FPC 11

Time to clinic quick or about right 8

Discreet pleasant helpful reception staff

8

Non-judgemental staff 8

Mix of patients in waiting area lends anonymity

5

Female staff in clinic 2

Staff professional and helpful, pt not made to feel bad or hurried

4

Military efficiency, gathering all info good idea

2

Lots of written information 1

Hospital easy to find 1

“They (Dean Terrace) were really nice, the doctor was great, really understanding. You feel bad enough yourself, you don’t want anyone making you feel worse. It was very clear and quick.”

“All very private, discreet and non-judgemental”

Results: service users

• Not all views ofassessment clinic were positive

Theme/comment No of replies/times mentioned

Would have preferred shorter wait from GP/FP to assessment clinic

9

Assessment clinic very long and complicated

8

Communal waiting area viewed negatively

5

Name being called on several occasions 4

Not enough information available in primary care

4

Negative attitude from GP or wrong info from GP

3

Distant/unfriendly/intimidating staff 3

Repetition of tests at GP and hospital 2

Excluding partner from clinical area 1

Getting through to family planning clinic on phone

1

“the doctor I spoke to said he didn’t deal with that so he would have to get someone else to speak to me -I didn’t like that”

“My name was called at least 4 times across the waiting room. Four times I was sent back out there!”

Results: service users follow up

• Positive commentsreflect those priorto procedure

• Negative comments despite extensive written information given to every patient

Theme/comment No. of replies/times mentioned

Supportive friendly staff 9

Information before was accurate about what happened

6

Non- judgemental attitude of staff

3

Efficiency and speed of visit 4

Pain worse than expected 7

Lack of accuracy about procedure 3

Poor signposting and information within hospital

2

Perception of coercion into MTOP 3

Results: providers

• Positive responses Description of issue Who is affected?

No of times mentioned

Reduced waiting times due to EMD/reorganisation of clinics

Patient 7

Integrated service means staff better informed re TOP, contraception etc

Patient/staff 4

Increased nurse-led services felt to be an advantage

Patient/staff 4

1st part of TOP given at assessment streamlines process for patient

Patient 3

Good private facilities for patients

Patient 3

Enjoyable supportive service to work in

Staff 2

Good relationship with primary care

Staff/patient 1

Reduced waiting times have made a huge difference; can make the difference between STOP and MTOP, or even having the termination at all

Nurse CY

Results:providers• Negative

responses

Theme/comment Who is affected?

No of times raised

Complexity and timing of assessment clinic (Both sites)

Patient 11

Difficulty dealing with TOP emotionally Staff 7

Waiting area (Both sites) Patient 6

Capacity at assessment clinic - rooms, staff

Staff/Patient 5

Fear of judgment– anonymity Patient 5

Delays due to capacity i.e. beds available within wards

Patient 5

Challenges providing effective follow-up contraception

Staff/Patient 5

Amount of information given to patients Patient 4

Privacy for procedure Patient 4

IT/paperwork Staff 4

Number of repeat abortions Staff/Patient 3

Difficulty accessing service Patient 3

Distance to Bruntsfield Suite from clinic Staff 3

Implementation of multiple changes to service

Staff 3

Staff cover for clinicians not wishing to be involved in TOP

Staff 2

Patients not attending – wasted resources

Staff 1

That whole waiting area needs to be looked at. That’s where we really fall down. The women might as well have a sign round their necks. Feel that its common knowledge that Bruntsfield is for TOP – ‘people know’.

Research Nurse

Results: suggestions for improvementFrom service users:• Increased information about pain

• Written info about other patients in waiting areas e.g. pregnant women

• Shorter, less complex assessment clinic

• Weekend appointments

• Encourage surgical methods

• Publicise EMD

Results: suggestions for improvementFrom service providers:

• Self referral

• Assessment/first medication in primary care

• Nurse-led service

• Move all EMD to new community SRH facility

• Weekend service

• Streamlined service, one practitioner performing scan, bloods, consent, counselling and arranging onward care

• Lean

Conclusion:

• Large busy TOP service• Meets HIS and RCOG Standards• Ascertaining the needs of women using

the TOP service is a difficult process• Flaws in system in general are minor• Improvements are feasible and many are

planned/in progress• Service users in general very pleased with

current pathway

Acknowledgements:

• Dona Milne, Specialist in Public Health, Edinburgh• Sheila Wilson, Senior health Policy Officer, Edinburgh• Staff at St John’s Hospital Livingston• Staff at The Royal Infirmary of Edinburgh• Women attending the TOP service in Lothian

Thank you