Second Edition Medical Abortion Training Guide ISBN: 1-933095-56-3 © 2010, 2013 Ipas. Produced in the United States of America. Suggested citation: Ipas. (2013). Medical abortion training guide (second ed.) K. L. Turner (Ed.), Chapel Hill, NC: Ipas. Ipas is a nonprofit organization that works around the world to increase women’s ability to exercise their sexual and reproductive rights, especially the right to safe abortion. We seek to eliminate unsafe abortion and the resulting deaths and injuries and to expand women’s access to comprehensive abortion care, including contraception and related reproductive health information and care. We strive to foster a legal, policy and social environment supportive of women’s rights to make their own sexual and reproductive health decisions freely and safely. Ipas is a registered 501(c)(3) nonprofit organization. All contributions to Ipas are tax deductible to the full extent allowed by law. Cover photo credits: © Richard Lord Illustrations: Stephen C. Edgerton The illustrations and photographs used in this publication are for illustrative purposes only. No similarity to any actual person, living or dead, is intended. For more information or to donate to Ipas: Ipas P.O. Box 9990 Chapel Hill, NC 27515 USA 1-919-967-7052 [email protected] www.ipas.org Printed on recycled paper. Ipas Medical Abortion Training Guide Acknowledgments This second edition of Ipas’ Medical Abortion Training Guide was revised by the following Ipas staff and consultants: Katherine L. Turner, USA, editor Jennifer Soliman, USA, revision coordinator Lead revision team: Alice Mark, USA Amanda Huber, USA Bill Powell, USA Joan Healy, USA Technical reviewers: Alyson Hyman, USA Anna de Guzman, USA Nadia Shamsuddin, USA The following Ipas staff and colleagues provided valuable inputs:* Alison Edelman, USA Mary Fjerstad, USA Bhagawati Badal, Nepal Makgoale Magwentshu, South Africa Dalia Brahmi, USA Meena Kumari Shrestha, Nepal Deeb Shrestha Dangol, Nepal Prativa Koirala, Nepal Ganesh Bahadur Singh, Nepal Tarun Poudel, Nepal Kalpana Khadsaka, Nepal Manish Aryal, Nepal i Ipas Medical Abortion Training Guide We give thanks to Ipas staff who contributed to the development of the first edition: Alfonso Carrera, Mexico Makgoale Magwentshu, South Africa Alyson Hyman, USA Mary Fjerstad, USA Bill Powell, USA Mary-Jane Zondo, South Africa Cansas Mulligan, USA Marian Abernathy, USA Ganesh Shrestha, Nepal Nadia Shamsuddin, Thailand Indira Basnett, Nepal Phan Bich Thuy, Vietnam Jennie Orcutt, USA Robyn Sneeringer, USA Joachim Osur, Kenya Rodolfo Gómez Ponce de León, Argentina Joan Healy, USA Sangeeta Batra, India Joseph Mills, Ghana Sarah Packer, USA Josephine Addy, Ghana Sikiratu Kailani, Nigeria Karen Trueman, South Africa Takele Geressu, Ethiopia Kari Koita, Kenya Tiemoko Ouattara, Burkina Faso Katherine Turner, USA Traci Baird, USA Karen Padilla, Nicaragua Laura Castleman, USA We give our appreciation to the Swedish International Development Agency for contributing funding to the development of the first edition of this training package through a grant to Ipas. ii Ipas Medical Abortion Training Guide We would like to thank the following people for giving their time and expertise to the development of Ipas’s Medical Abortion Training Program:* Ali Samba, Ghana Lisa Moreau, USA Alison Edelman, USA Meera Ojha, Nepal Anne Burke, USA Meera Upadhyay, Nepal Beth Kruse, USA Melanie Peña, USA Beverly Winikoff, USA Mitchell Creinin, USA Blami Dao, Burkina Faso Nitin Joglekar, India Caitlin Shannon, USA Nguyen Thi Nhu Ngoc,Vietnam Chanda Karki, Nepal Paige Layno-Winn, USA Christina Wegs, USA Paul Blumenthal, USA Danielle Hassoun, France Phillip Stubblefield, USA Dalia Brahmi, USA Pramila Pradha, Nepal Fabian Rodriguez, Uruguay Rodica Comendant, Moldova George Huggins, USA Selma Hajri, Tunisia Hela Chelli, Tunisia Shilu Aryal, Nepal Helena Von Hertzen, Switzerland Suchitra Dalvie, India Joe Taylor, Ghana Swaraj Rajbhandari, Cambodia Kusum Thapa, Nepal Lisa Memmel, USA *The protocols and content in this publication do not necessarily reflect the views and opinions of each individual contributor. We give special thanks to the many colleague agencies who field tested the first edition of the training package: Nepal Training on Medical Abortion for Lead Trainers and the Family Health Division, Government of Nepal Africa Regional Training of Trainers on Medication Abortion and the Centre de Formation Internationale et de Recherche (CéFIR), Tunisia Cambodia Technical Working Group on Medical Abortion and the National Reproductive Health Program, Government of Cambodia South African Medical Abortion Curriculum Review Committee iii Ipas Medical Abortion Training Guide Table of Contents Module 1: Medical Abortion Overview ...................................................................... 1 A. Introduction and training overview ...........................................................................................1 B. MA study guide review: MA quiz show .....................................................................................3 C. MA study guide review: Pre-test ...............................................................................................3 D. Overview of medical abortion ...................................................................................................4 Module 1: Materials .................................................................................................................6 1. MA Quiz Show instructions (for trainers) ........................................................................7 2. MA Quiz Show question-and-answer key (for trainers) .................................................10 3. Medical abortion pre/post-test ....................................................................................20 4. Medical abortion pre/post-test answer key (for trainers) .............................................25 Module 2: Medical Abortion Regimens .....................................................................31 A. MA eligibility: Contraindications, precautions, and special considerations............................31 B. MA regimens ..........................................................................................................................30 Module 2: Materials ...............................................................................................................40 1. Contraindications and precautions for MA (for participants) .......................................41 2. Contraindications and precautions for MA (for trainers) ..............................................42 Module 3: Clinical Care ..............................................................................................43 A. Pre-procedure care ..................................................................................................................44 B. Clinical assessment: Role of gestational dating ......................................................................45 C. Gestational dating by last menstrual period (lmp) ..................................................................45 D. Gestational dating by bimanual examination .........................................................................38 E. Identifying ectopic pregnancy .................................................................................................49 F. Determining MA eligibility: Clinical assessment case studies ..................................................51 G. Identifying symptoms and signs .............................................................................................52 H. Expected effects .....................................................................................................................53 I. Possible side effects ..................................................................................................................55 J. Warning signs ...........................................................................................................................56 Module 3: Materials ...............................................................................................................58 1. Key components of pre-procedure care strips (for trainers) .........................................59 2. Clinical assessment case studies (for participants) .......................................................60 3. Clinical assessment case studies answer key (for trainers) ...........................................61 4. Side-effects continuum instructions (for trainers) .........................................................64 5. Side-effects continuum strips (for participants) ............................................................68 6. Side-effects continuum answer key (for trainers) ..........................................................69 iv Ipas Medical Abortion Training Guide 7. Proportion of women who experience a side effect (for participants) .........................70 Module 4: Informed Consent, Information and Counseling ....................................71 A. Information provision and woman-centered counseling .........................................................72 B. Comfort level with medical abortion .......................................................................................74 C. Counseling role plays ..............................................................................................................76 D. Postabortion contraceptive counseling ..................................................................................77 Module 4: Materials ...............................................................................................................79 1. Comfort continuum statements (for trainers) ...............................................................80 2. Information provision and woman-centered counseling: Key elements (for trainers) ..81 3. Role plays for counseling and information (for participants) ........................................83 4. MA skills checklists (for participants) ............................................................................85 5. Contraceptive counseling scenarios (for participants) ..................................................93 6. Contraceptive counseling scenarios key considerations (for trainers) ..........................94 Module 5: Follow-up care ..........................................................................................97 A. Providing follow-up care .........................................................................................................97 B. Confirming the MA worked .....................................................................................................98 C. What to expect at a visit after MA ..........................................................................................99 D. Telephone support ................................................................................................................101 Module 5: Materials .............................................................................................................105 1. Telephone support role play scenarios (for participants) ............................................106 Module 6: Problems, Complications, and Emergencies ..........................................109 A. Overview of problems and complications .............................................................................109 B. Case studies ...........................................................................................................................111 C. Responding to medical emergencies ....................................................................................111 Module 6: Materials .............................................................................................................113 1. Medical abortion problems, complications and emergencies case studies (for participants) ..........................................................................................................114 2. Medical abortion problems, complications and emergencies case studies answer key(for trainers and participants) ....................................................................117 Module 7: Service Provision .....................................................................................119 A. MA service provision considerations .....................................................................................119 B. Taking MA at the clinic or at home .......................................................................................121 C. Barriers to MA access ............................................................................................................122 Module 7: Materials .............................................................................................................123 1. Preparing a site to provide MA services worksheet (for participants) ........................124 v Ipas Medical Abortion Training Guide Module 8: Clinical Practicum ...................................................................................125 A. Practicum overview ...............................................................................................................125 B. Supervised clinical practice ...................................................................................................127 C. Post-practicum debriefing .....................................................................................................127 Module 9: Final Assessment and Closing ................................................................129 A. Review expectations, objectives and parking lot ..................................................................129 B. Post-test and evaluation ........................................................................................................130 C. Closing circle .........................................................................................................................130 D. Certificates ............................................................................................................................130 Module 9: Materials .............................................................................................................133 1. Final evaluation form (for participants) .......................................................................134 2. Certificates of competency or completion (on CD-ROM) References ................................................................................................................138 Appendices ..............................................................................................................141 A. Sample schedule and agenda ..............................................................................................141 B. Four corners activity ..............................................................................................................143 C. Guidance for choosing a practicum site ...............................................................................147 Ipas abortion-related training and service delivery curricula and other resources CD-Rom – Relevant materials for this curriculum: Medical Abortion Study Guide (pdf file) Medical Abortion Training Guide (pdf file) Medical Abortion Training Guide Powerpoint Presentation (ppt file) Quiz Show Powerpoint and Flash Plug-in (ppt and swf file) Medical Abortion in Early Pregnancy: Information, Education, and Communication (IEC) Materials and Job Aids MA Supply Guidance Spreadsheet (xls file) Woman-Centered, Comprehensive Abortion Care: Reference Manual and Trainer’s Manual, Second Edition (pdf and ppt files) Abortion Care for Young Women: A Training Toolkit (pdf and ppt files) Effective Training in Reproductive Health: Course Design and Delivery. Reference Manual and Trainer’s Manual (pdf and ppt) vi Ipas Medical Abortion Training Guide Medical Abortion Training Guide The Medical Abortion Training Guide, Second Edition is one of two companion documents in the Ipas medical abortion (MA) training package. • Medical Abortion Study Guide, Second Edition – to be used for self- directed study prior to attending an in-person workshop and clinical practicum and as a resource document for future reference. • Medical Abortion Training Guide, Second Edition – to be used by clinical trainers to lead participants through an in-person workshop followed by a clinical practicum. All the clinical information in this manual is up-to-date at the time of publication. For updated clinical guidance, please see the Clinical Updates for Reproductive Health series at Ipas’s website, www.ipas.org. The Medical Abortion Training Guide, Second Edition includes activities and materials for trainers to use in helping health-care workers acquire the appropriate knowledge, attitudes and practical skills they need to provide first-trimester medical abortion. The Training Guide is divided into nine modules: seven workshop modules, a clinical practicum module, and an assessment, evaluation and closing module. Each module strengthens knowledge and skills for a specific component of MA service delivery. Trainers are highly encouraged to adapt the modules to fit the local training needs and objectives. Objectives Upon completion of the Medical Abortion Training Guide, Second Edition, learners should be able to: 1. Explain Ipas-recommended MA drug regimens 2. Describe eligibility, contraindications and precautions 3. State expected and potential side effects of MA 4. Explain information the woman should know about MA, including warning signs to seek medical care 5. Identify when women need urgent follow-up care 6. Identify personnel, facility, record-keeping and supplies requirements needed to implement MA services at their work site 7. Provide the information, counseling, clinical assessment, identification and treatment of problems and complications necessary to provide MA in their own clinical setting vii Ipas Medical Abortion Training Guide Each module contains activities and materials to reinforce information participants have learned from their self-study of the Study Guide— recommended regimens, eligibility, clinical care, counseling and information and service delivery issues—and includes five elements: 1. Time: An estimate of how long it should take to complete the module 2. M odule Objectives: Specific objectives to be met by the end of each module 3. A dvance Preparations: Instructions regarding information or materials to be prepared ahead of time 4. I nstructions and Materials: A list of the handouts, presentations, and other resources needed for each activity, followed by step-by-step guidance on how to facilitate interactive learning 5. C opies of all learner materials for distribution and answer keys for trainers Note: The Study Guide is considered a basic resource document to be used throughout the training course. If PowerPoint (PPT) presentations are not possible, trainers can copy PPT slides onto transparencies or use photocopies as handouts. Second edition This training guide is designed to train providers on the delivery of high- quality, clinic-based, first-trimester medical abortion (MA), particularly in limited-resource settings. This second edition has been updated to reflect the latest evidence from the World Health Organization (WHO) and other important source documents. These updates include current clinical evidence and recommendations on providing appropriate MA care to young women and working with communities to improve information, social support and access. This curriculum focuses on provision of MA by trained health-care providers working in facilities in the formal health-care system. There is increasing attention on making MA information and drugs more widely available to women in real and virtual communities outside the formal health system, particularly in settings where women face serious risks due to lack of access to safe services. Ipas has policies, materials and programs to support these efforts. In this second edition, we have included some recommendations on how to increase access and improve linkages between communities and health facilities. For more information, please see the Community Access section in Additional Resources of the Medical Abortion Study Guide, Second Edition. In this second edition, we also address young women’s unique needs in an effort to increase MA service delivery and access. Young women viii