Choices: The Question

  ** Names and details have been changed to protect patient confidentiality, privacy, and dignity **
Jenna presented to the prenatal clinic last week, looking younger than her stated age of 15. She was accompanied by her mother, who had a toddler in tow. The tension between mother and daughter was palpable. Through extracting the history, I learned that Jenna was 4-6 weeks pregnant, identified during a routine school physical, and she was unsure of her last menstrual period, as well as the sexual encounter which led to the pregnancy. We struggled through a family history based on Jenna's recollection, since her mother was not willing to contribute any information, and avoided Jenna's pleading stares by adjusting the younger brothers' jacket.

When the resident arrived, we took her to the examination room for a pelvic exam. Jenna had never heard of a Pap smear, let alone had one. She tolerated our poking, prodding, and manipulations well, though visibly disturbed to learn that she would have to endure more of these exams as her pregnancy progressed. We attempted to engage her with small talk around her aspirations, her social life, and her plans to watch the new "Twilight" movie, but she was quite withdrawn. It was understandable, given the circumstances. 

After the exam, we rejoined her mother. The disappointment in her daughter, guilt of the situation, and stress of keeping a toddler occupied in the office had taken their toll on her. Mother and daughter quickly engaged in a verbal altercation involving a newly received text message. My resident escorted sobbing mother and wailing toddler out of the room to calm them, while I remained with Jenna. 

So there we were. 

I asked Jenna if she had any questions. She shook her head "no". I briefly explained the purpose of pelvic exams, prenatal vitamins, and blood testing while she fiddled with the zipper of her hoodie. One remaining question ate at me, needing to be asked.

"Has anyone talked to you about whether or not you wanted to keep the baby?" 

Jenna's head flew up. "No, they haven't." She relayed that her boyfriend did not believe in abortion, but she wasn't sure what to do. She was scared to ask about her options for abortions, not knowing her mother's stance on the matter. Her pediatrician provided the prenatal vitamins and referred her to the office, without discussing the option of termination. Jenna lacked even the basic knowledge of medical or surgical abortions.

Should women receive information regarding the termination of pregnancy on their prenatal visits? Does the moral position of the physician matter? In my previous post Choices, I described the graphic nature of surgical abortions and my reconsideration of my strict Pro-Choice beliefs. I didn't want to encourage Jenna to have an abortion, but felt that she needed the information to make an informed decision. In the age of patient autonomy, all options for treatment should be discussed. Was Jenna too young to understand these serious issues? Possibly. Should I have waited until her mother was calm and ready for discussion? Perhaps. Would it be appropriate to refer Jenna to a clinic for more information? I'm not ethically certain. I felt it was my duty to at least ask the question.

After the storm had settled, Jenna's mother, brother, and the resident rejoined us. We scheduled an appointment for next month, which would still give Jenna time to decide if she wanted to continue the pregnancy. Mother was still a bit hostile, and Jenna still subdued, but seemed to be relieved that there were other options available to her.