Pregnancy counseling and abortion referral for patients in federally funded family planning programs.

Family planning programs often see patients who have medical or social problems that are unrelated to fertility regulation or that require interventions beyond the program's capabilities. Both professional standards and the regulations governing federally funded family planning projects require that such patients be apprised of their condition, counseled as to alternatives and referred to an appropriate resource for care. Organized family planning programs funded under Title X of the Public Health Service Act and Title V of the Social Security Act, nevertheless, may feel constrained from making abortion referrals because of the prohibition in the Title X law and Title V appropriation against use of federal funds to pay for abortion as a family planning method. However, program guidelines for Title X have just been issued which should resolve the ambiguities that have arisen around interpretation of this prohibition. Indeed, a close examination of the relevant laws, the legislative history of the prohibition a nd subsequent congressional action on abortion indicates that Congress never had any intention of restricting pregnancy counseling or abortion referral services. Moreover, the failure to offer such services, when called for, is probably a violation of federal regulations as well as professional standards and principles.

Family planning programs are financed largely under Title X and, to a much smaller extent, Title V. The federal regulations governing Title X state that "the project will not provide abortions as a method of family planning." (1) They require, however, that "provision [be made] for medical services related to family planning ... and [for] necessary referral to other medical facilities when medically indicated," and that there also be made available "social services related to family planning, including counseling, referral to and from other agencies [and] coordination and use of referral arrangements with other providers of health care services." (2) The new DHEW guidelines interpreting these regulations add that family planning medical services "should be part of a comprehensive medical care plan where patients served by a family planning project may receive education, advice and referral for the screening, detection, prevention or treatment of a variety of conditions with the objective of achieving and main taining a state of good health, particularly with regard to reproduction." (3) The guidelines provide, for example, that patients be given a full explanation of the benefits and problems associated with all of the various contraceptive methods. (4)

Special attention is given to the medical management of patients who are or may be pregnant. Among lab tests which must be provided at the initial visit is a "pregnancy test, if indicated. " (5) The interview following the medical examination should "give pregnancy counseling, when appropriate, . . . [and] make appropriate referrals for any needed services [including pregnancy-related services] not furnished through the facility." (6) Thus, if an IUD patient is diagnosed as pregnant, the IUD should normally be removed. If it is not, the patient should be advised that there is an increased risk of an infected, spontaneous abortion during the pregnancy, and "the patient and her physician should discuss whether it is best to terminate or to continue the pregnancy. . . . Whatever the decision regarding the pregnancy, she must have close medical supervision [emphasis added]." (7) The guidelines also provide for counseling of patients who wish to discontinue their contraceptive method in order to become pregnant. T he counseling should emphasize the need for "early and continuing care during pregnancy, with referral to sources giving prenatal care." (8)

Under Title V, DHEW approval of each state's "program of projects" is conditioned upon assurance that the program has made "arrangements for the provision of services to those persons who have received diagnostic tests but are not eligible for treatment services under the program of projects," and that arrangements exist for the "coordination of health care and services provided under the program with, and the utilization of other health and welfare resources." (9)

Quite apart from the federal regulations and guidelines governing these programs, professional ethics and standards require that patients be counseled and referred to other sources of care or assistance when needed and available. Indeed, the Principles of Medical Ethics of the American Medical Association state: "A physician should seek consultation [referral] upon request; in doubtful or difficult cases; or whenever it appears that the quality of medical service may be enhanced thereby." [10] Failure to make appropriate referrals could, under certain conditions, provide the basis for malpractice action. In the case of projects funded under Title V and Title X, failure to comply with the governing DHEW regulations could disqualify the program from receiving federal support.

The determination and management of pregnancy are among the most common conditions necessitating counseling and referral that are encountered by family planning programs. Pregnancy requires medical monitoring in all circumstances, and medical intervention and treatment if and when problems arise. It is generally agreed that medical care should be provided as early as possible in pregnancy, either to ensure optimum conditions for the woman and her fetus throughout the gestational period or, alternatively, to terminate the pregnancy in the early weeks when the risks to the woman are fewest. Family planning project personnel have had no difficulty in counseling and referring for prenatal care those patients who are pregnant and desire to continue their pregnancies to term. In projects that are funded in whole or in part by Title X or Title V funds, however, some professional staff have felt constrained from providing abortion counseling and referral services for those patients who want them. These constraints h ave resulted in part from the perceived ambiguity of the law, and in part from the varying informal interpretations provided by DHEW personnel in different geographical areas at different times, especially in the absence of any guidelines. Although the new guidelines should clarify any ambiguities about interpretation of the law, it may nevertheless be worthwhile to review the relevant legislative history to forestall future misinterpretation or misrepresentation.

Section 1008 of Title X was adopted as part of the original Title X legislation (11) and subsequently was extended to Title V in legislation dealing with appropriations. (12). It reads: "None of the funds appropriated under this title shall be used in proprams where abortion is a method of family planning."