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Termination of Pregnancy in Lothian A Health Needs Assessment

Termination of Pregnancy in Lothian A Health Needs Assessment. Rosemary Cochrane Subspecialty trainee Chalmers Centre for Sexual and Reproductive Health Edinburgh November 2011. Aims. describe the population accessing termination of pregnancy services in Lothian

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Termination of Pregnancy in Lothian A Health Needs Assessment

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  1. Termination of Pregnancy in LothianA Health Needs Assessment Rosemary CochraneSubspecialty traineeChalmers Centre for Sexual and Reproductive HealthEdinburghNovember 2011

  2. 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

  3. 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.

  4. 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

  5. Abortion mapping – over 20 years • Terminations from Depcat 1-2: • 22.3 / 1000 in 2007 • 16.9 / 1000 in 2010.

  6. 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

  7. 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

  8. Patient pathway N2 N2 N1 D US N1 D US CSW CSW T T REC W/A W/A REC Key: REC = Reception D = Doctor’s room W/A = waiting area N1 = First nurse’s room T = toilet N2 = Second nurse’s room US = Ultrasound room CSW = Clinical support worker

  9. 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

  10. RCOG and FSRH Consensus Statement 2008 Delays in referralassociated 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.”

  11. 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.

  12. 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

  13. Methodology • Service users and service providers interviewed • 17 staff members and 17 service users • Staff • Doctors • Nurses • Receptionists • Sonographer • Clinical support workers • Managers

  14. 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

  15. In general, women were very satisfied with the service they received Results: service users “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”

  16. Results: service users • Not all views of assessment clinic were positive “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!”

  17. Results: service users follow up • Positive comments reflect those prior to procedure • Negative comments despite extensive written information given to every patient

  18. Results: providers • Positive responses 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

  19. Results:providers • Negative responses 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

  20. Results: suggestions for improvement From 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

  21. Results: suggestions for improvement From 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

  22. 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

  23. 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

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