Feminist Midwife Scripts: Positive Pregnancy Test
After requests to detail the language I use in different midwifery care scenarios, I am starting a series of "scripts." With these example texts, I seek to provide a springboard for providers, care seekers, and reproductive health workers to discuss possible best practices for language and approach in different scenarios. I will update each script with language and ideas shared here and on social media to work toward creating an environment of true empowerment, respect, and care in obstetrical and gynecological health.
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Visits for pregnancy testing can be wrought with anticipation, cautious celebration, impending fear, exploding joy, unwavering negativity, confirmation of fertility, and generalized uncertainty. In my (almost) four years of midwifery practice, I have seen people's positive pregnancy tests mean so, so much more than just the two lines. A positive pregnancy test can verify suspected circumstances of assault, cause people to drop to their knees in happiness after years of trying, validate someone proving they can do what they want with their body despite others trying to control it or validate someone else's control over their body, and also be just another day seemingly unaffected by a test result.
I try my darndest to walk into each room and visit with a clear mind, shaking off the visit before, shaking off my own "stuff," not assuming anything about how anyone feels about their day and their current life, let alone the test results.
My biases related to conversations of positive pregnancy testing are as follows: I believe people have equal rights to choose to parent / adopt / terminate pregnancy, I am personally not planning children, I acknowledge I know little about the depths to which a positive pregnancy test impacts someone's complicated life right now and in the future, I think pregnant women and pregnant people are awesome humans, I think women and people who choose not to have nor continue pregnancies are awesome humans, I think people who choose an adoption plan are awesome humans, I think babies are snuggly squishy little love muffins, and I think if someone changes their mind about their plans for the pregnancy anywhere in the process that is to be supported and cared for as equally as their initial decision.
A few notes:
The visit to discuss a positive pregnancy test might not be the visit where plans for pregnancy are decided. Some people need time: for themselves, to talk with their partner, to discuss with family, to map out all of the options. If the pregnancy test seems like it weighs enough in the visit to need more time, offer a return visit the next day or the next week.
If decisions to continue versus terminate the pregnancy may be time-sensitive given preferred method of termination or state laws around terminating based on certain criteria (anomalies, mental health, etc.) then be up front about that when discussing abortion as an option and/or offering more time to decide.
In situations of sexual assault, the pregnancy may not be the focus of the first visit. Let the person you're honored to care for guide the discussion, or provide gentle guidance and check in with them on the pace and topics.
If you have personal opinions about "certain types of people" choosing "certain types of pregnancy decisions," drop 'em now. Your job is to take care of people and create space for them to build their best and healthiest life, however they define that. Want a gut-check quiz? Here ya go. A 16 year-old with her similar age partner, very excited! A 44 year-old very excited about the successful IVF pregnancy, but with late diagnosed anomalies choosing termination. A 21 year-old with an abusive partner, unable to negotiate contraception, choosing termination for the third time this year. A 38 year old with 9 children at home, very excited! With any visit there will be important times to guide the conversation toward topics of personal choice, empowerment, safety, etc. so do not let your reactions about the pregnancy test for "that person" affect how you meet them where they are in their own assessment.
If they ask you what you think they should do, redirect like in any other circumstance: I want you to do whatever you feel is the best decision for you right now. And if you aren't sure about that today, let's find ways to help you get to that decision and let's come back together soon.
Some people find this visit the safest space to express how they feel about prior pregnancy decisions. "I am so proud of myself for choosing abortion the last time, because I wasn't ready, and now I'm not as sure what the right decision is for me." "I shouldn't have continued with the last pregnancy because my hands were already full, but I love my youngest, and I'm sure I'll love this one too." "I haven't been able to get over the abortion, and I haven't been able to talk with anyone about it." "I chose adoption years ago and I don't know how I could ever do that again." Give space for people to process their prior choices. A phrase I often say is: "You made the best decision you could for yourself at that time. And I am proud of you for that. You are a different person now and you might think about the choice differently, but be kind to the person who made that choice then. Now let's do the same today and figure out what's the best decision for you based on what's going on."
Know the laws in your state about having parents present for clinic visits with adolescents. During any first visit when family or friends are present (pregnancy testing or otherwise), I usually cover the standard history and questions, then say "Thanks so much for coming! It means so much to me as a provider to see supportive family here with the people I take care of. For the rest of the visit, thanks for waiting in the waiting room until we come out to get you." (Like with anything else - read the situation. If the person clearly wants the supportive presence, then modify this statement or your response if the person asks for everyone to stay.)
Know your state laws around judicial bypass for abortion, which is how minors can access abortion care without notifying a parent or guardian. Here's information on judicial bypass in the state where I practice.
Know your referral sites, screen them, and ensure you are not sending someone to a center where their decision would be coerced or they would receive incorrect information.
The numbering system below has nothing to do with how I rank pregnancy choices. It is in no particular order (NPO).
With that in mind, here is how I approach the discussion around a positive pregnancy test. Really, this script just scratches the surface of where the conversation begins and can go based on people's needs. At many points in the script, there are places where the conversation can veer differently: I've tried to address those at each point, and numbered to help start at one script and progress to the next, but scroll to the bottom if you'd like to see a summarized flow chart to organize your thoughts that way as well. Each of the options one might choose would lead the conversation down a more in-depth path, which I will address in future scripts (choosing abortion, choosing adoption, choosing parenting). For now, just the main points I go over during the results visit.
Here's the script.
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Hi, I'm Stephanie, the midwife here with you today. (Or Hi, I'm Stephanie, it's good to see you again.)
Your pregnancy test today is positive.
Pause and wait for a verbal response, facial expression, body changes.
Tell me how you're feeling about that....Possible responses:
I know! I'm so excited! --> Great, let's get started! (Begin prenatal care (which won't be discussed in this post), but at some point jump to the part below that starts "Regardless of response about plans for the pregnancy..." and be sure to include that before the visit is over.)
Ugh, I'm so nauseous and exhausted. --> Ah, I'm sorry, that's a hard way to feel. How has that been for you? (If symptoms are the most prominent conversation for them, focus on those! Address nausea, fatigue, cramping, spotting... normalize common first trimester issues, note possible clinical concerns for hyperemesis or abnormal bleeding to discuss later in the visit. Eventually re-route the conversation back to their feelings on the positive pregnancy test, to address plans so that the other concerns can be handled within the context of those plans.)
I figured. Well, here we go again. --> Tell me more about that. (Focus on this as long as they need to, and then continue based on their response. At some point jump to the part below that starts "Regardless of response about plans for the pregnancy..." and be sure to include that before the visit is over.)
I'm really not sure. --> Okay. Let's talk through what you're not sure about. (See bullet point above about giving people time and space to figure things out. Sometimes making pro-con lists, or suggesting finding an objective person in their life with whom to talk things through, might be ways to direct their thoughts outside of the clinic visit.)
I know. I need to know how to get an abortion. --> Okay. Here's the information and how that process works. (At some point jump to the part below that starts "Regardless of response about plans for the pregnancy..." and be sure to include that before the visit is over.)
I know. I'm choosing adoption. (At some point jump to the part below that starts "Regardless of response about plans for the pregnancy..." and be sure to include that before the visit is over.)
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3, 4. For those uncertain or those planning to continue but currently speaking negatively about that decision --> Okay, let's talk through a few things. Sometimes pregnancy happens exactly when we want it to, or it happens at exactly the wrong time. Sometimes it's automatically exciting, and sometimes it's just neutral, and sometimes it's really frustrating or sad. Sometimes pregnancy happens and we feel like we have control over what's next, and sometimes we don't. All of those things are okay to experience and feel. Where do you feel like you're at with some of those thoughts?
5. For those planning abortion--> Okay, let's talk about that. Based on the first day of your last period / the day you know you got pregnant, here are your options. You would first have an ultrasound to verify how far along you are. Then the provider would discuss your options. If you are before 10 weeks, you could take a series of pills, one in the clinic and one at home, which would cause a heavy period and the pregnancy would come out with the cramps and blood. If you are after 10 weeks, or if you would prefer, you could have a procedure where the provider looks inside the vagina and inserts a tool into the uterus to clean out the pregnancy, which may cause some cramping and pain, but there are medications you can take to help with the discomfort. How do you feel about those two options? What questions do you have?
6. For those planning adoption --> Okay, let's talk about that. There are points during the pregnancy when you can explore this further. Many who know early on will begin the process right away. Some, even though they know early on, may choose to start the process later. There are lots of options, including different types of open adoption, family adoption, and various parenting and support scenarios people may choose. How do you feel about those options? What questions do you have?
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3,4 (or, really, any of the choices): Sometimes a positive pregnancy test can feel overwhelming. Do you feel ready to keep talking about it today, or do you want to think about things and come back next week to talk about your questions or choose next steps?
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Regardless of response about plans for the pregnancy, at some appropriate point during the visit, I say:
1, 2, 3, 4, 5, 6. As your provider, it's important for me that you know this is a safe space to talk about all options related to the pregnancy. Everyone's life and support systems are different, and if you have people in your life who expect you to feel just one way about the pregnancy, or who put their plans for your life onto what's expected for you related to this pregnancy, I need you to know that's not what I'm here to do. I'm here to take care of you, and to help you figure out the best ways for you to care for yourself. If at any point your plans for the pregnancy change, I'm here to support you in that, help you navigate those thoughts and decisions and care.
A couple misconceptions about abortion I do want to clear up, just so I know you have received correct information as you make your decisions. Abortion is a safe and legal procedure. Having an abortion does not affect your ability to get pregnant in the future if that's something you decide. If you need to figure out how to have an abortion without telling anyone in your life it happened, or if people know you're pregnant and you need to tell them you had a miscarriage, we can talk about what that would look like.
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3, 4, 5, 6. I know it can be hard to talk about all of this at once, with someone you just met / with someone you have known in other circumstances (if I was the provider during their last pregnancy, or if I take care of a family member of theirs). We can continue at a different visit, or I can give you a follow-up with another provider, or there's a confidential call-line I can give you and you can talk with someone on the phone. (Information for Backline available here.)
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What other questions do you have for today?
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I know we went over a lot of information today. If you leave and have questions, here's how to contact me. I'm in the clinic on (these days), and you can follow-up with another provider on (these days).
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Readers, looking forward to your comments! - Stephanie
(Providers - my favorite resource on this topic is Alissa C. Perrucci's "Decision Assessment and Counseling in Abortion Care." There's a chapter on "Decision Counseling for Positive Pregnancy Test Results." Check it out!)
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I wish I were technologically advanced enough to be able to create an electronic flow chart that looks fancy and well-designed, but instead, here's my daughter-of-an-artist-who-lacks-artistic-ability sketch. (Adoption algorithm covered above, ran out of space on the paper.)
