How do you help patients decide between pregnancy termination options?

Highlights

• The patient's choice is personal, depending on their values and whether they prefer an at-home process or a clinical setting.
• Medication abortion offers a private, multi-day experience at home that gives the patient more autonomy over the process.
• Procedural abortion is a quick, scheduled event in a medical facility with various sedation options and a sense of finality.
• Medical factors, such as gestational age beyond 11-12 weeks or severe anemia, may make procedural abortion the recommended option.
• Procedural abortion is nearly 100% effective, while medication abortion has a 95% success rate and may require follow-up intervention.

Article

The Centrality of Patient Values in Decision-Making

When counseling patients on pregnancy termination, the primary clinical objective is to facilitate an informed choice that aligns with the individual’s personal values and circumstances. Dr. Sarah Prager emphasizes that the clinician's role is not to decide for the patient, but to clearly delineate the two primary first-trimester options—medication and procedural abortion—so the patient can determine which process is best for them. Both are safe and effective methods. As Dr. Alison Edelman observes, with clear information about what each process entails, patients are generally able to determine which option is right for them. The decision hinges on factors such as the patient's desire for privacy, comfort level within a medical environment, and preference for the timing and nature of the experience.

"No clinician can make that decision for a patient. It is completely up to each individual person to decide what is gonna be the best option for them." Dr. Sarah Prager

The Medication Abortion Experience

A medication abortion is often chosen by patients who value autonomy, privacy, and a process that occurs outside of a clinical setting. Dr. Kari Braaten notes that this method offers flexibility, allowing a patient to schedule the process at a convenient time and be in the comfort of their home with support people. The regimen involves taking one medication, followed by another 24 to 48 hours later, which induces the abortion process, as described by Dr. Ana Cepin. Dr. Prager adds that some patients prefer this option specifically because it does not involve uterine instrumentation. Dr. Bartz notes that patients often feel this method provides a greater sense of ownership and seems more "natural." However, it is a more "active process," as Dr. Braaten describes, involving significant cramping and bleeding that, while reassuring to some as an experience similar to miscarriage, can be uncomfortable for others.

"People really like this method in that they feel like they have greater ownership. It's more private, it's more natural." Dr. Deborah Bartz

The Procedural Abortion Experience

In contrast, a procedural abortion is often selected by patients who prefer the security of a medical facility and the finality of a discrete event. Dr. Prager states that these patients appreciate being observed by medical professionals and leaving the facility knowing the process is complete. This sense of finality is a key differentiator; Dr. Deborah Bartz highlights that when a patient leaves the procedural unit, she is no longer pregnant and rarely requires further follow-up. Dr. Edelman points out that this option is often faster and may be preferable for patients concerned about pain, as it allows for a range of sedation and anesthesia options that are not available with medication abortion. As Dr. Cepin explains, the procedure can be done in an office with local anesthesia or in a facility under sedation, depending on provider offerings and patient preference.

"When a patient leaves the procedural unit, she's done, she's no longer pregnant and she rarely needs any other kind of follow-up." Dr. Deborah Bartz

Clinical Parameters and Efficacy

While patient experience is paramount for eligible individuals, certain clinical factors can steer the decision. Dr. Bartz notes that some patients may have a medical condition that precludes medication abortion, such as severe anemia, due to the higher associated blood loss. Gestational age is another critical factor; medication abortion is typically available only up to 11 or 12 weeks of gestation in the United States, making procedural abortion the necessary option for patients further along. Efficacy rates also differ. According to Dr. Bartz, procedural abortion is "almost unanimously successful," with an efficacy approaching 100%. Medication abortion has a success rate of approximately 95%, with the remaining 5% of patients requiring additional intervention, such as another dose of medication or a subsequent procedural abortion to complete the process. This also highlights the difference in follow-up, which is typically required for a medication abortion but not for an uncomplicated procedural one.

The Clinician's Role: Facilitating an Informed Choice

Ultimately, the physician's role is to serve as an expert resource, clearly articulating the distinct experiences of medication versus procedural abortion. The discussion should cover the setting (home vs. clinic), timeline (a multi-day process vs. a single-day procedure), degree of patient involvement, pain management options, and efficacy. By presenting these factors, clinicians empower the patient to weigh their priorities regarding privacy, medical supervision, discomfort, and the need for a definitive endpoint. As Dr. Prager concludes, the decision is "completely up to each individual person." The optimal choice is the one that best fits the patient's unique lifestyle, values, and psychological needs.