Proposed Indian Health Service Guidelines For Provision of Reproductive Health Care
The purpose of these policies is to provide guidance for medical professionals in the care of women’s reproductive services, especially timely services for survivors of sexual assault. Once adopted by the Indian Health Services headquarters (hereinafter “I.H.S. Headquarters”), these policies shall pertain to and be followed by all Indian Health Service Units and Emergency Rooms, Direct Care Facilities, and Contract Health Services (hereinafter “I.H.S Facilities”).
I. GENERAL PROVISIONS
a. All I.H.S Facilities shall either provide or make referrals for reproductive health services on request. I.H.S. shall pay for the cost of services resulting from all such services or referrals.
b. I.H.S. Headquarters shall establish standardized protocols for the delivery of information regarding all I.H.S. coverage for reproductive health care services.
c. I.H.S. Headquarters shall establish a Sexual Assault Management Protocol and mandate that each I.H.S. Facility post a copy of the Sexual Assault Management Protocol for attending medical staff to reference.
d. I.H.S. Headquarters shall establish standardized protocols mandating that all I.H.S. Facilities provide reproductive health care in a culturally acceptable, gender sensitive, respectful, unbiased and confidential manner.
e. All I.H.S. Facilities shall strictly maintain patient confidentiality.
f. Memoranda of Understanding between I.H.S. Headquarters and contracted facilities shall reflect and be subject to this policy.
II. CONTRACEPTIVES
a. I.H.S. Facilities shall inform women seeking to prevent pregnancy verbally and in writing of the full range of FDA – approved contraceptive options, including emergency contraception.
b. I.H.S. Facilities shall provide women with the contraceptive method of their choice, including an advance prescription for emergency contraception.
III. PREGNANCY-RELATED CARE
a. I.H.S. Facilities shall provide, in writing and verbally, all women who request information related to pregnancy options with the relevant information in a comprehensive, non-directive, unbiased and confidential manner. This will include information on:
i. Prenatal care and delivery;
ii. Infant care, foster care and adoption; and
iii. Pregnancy termination (surgical and medical).
b. I.H.S. Facilities shall inform women who request information about an abortion, provision of an abortion, or a referral for an abortion of the following:
i. I.H.S. shall pay for an abortion where the pregnancy results from rape or incest or endangers the woman’s life;
ii. Whether the Medicaid program in that state is required to cover abortions in additional situations (e.g., instances of fetal anomalies or medically necessary abortions);
iii. Whether I.H.S. and/or Medicaid are required to cover transportation costs associated with obtaining an abortion; and
iv. Available support services at I.H.S. Facilities, such as counseling and aftercare.
c. I.H.S. Facilities shall provide all needed assistance to access abortion services on-site or through contracted services to all women who request such assistance and whose pregnancy results from rape or incest or endangers the woman’s life.
d. I.H.S. Facilities shall assist women who wish to seek Medicaid coverage of an abortion in enrolling in Medicaid if eligible and in obtaining a Medicaid covered abortion.
IV. SEXUAL ASSAULT SURVIVORS
a. I.H.S. Headquarters will establish standardized, written protocols for the delivery of information and services to sexual assault survivors in a culturally acceptable, gender sensitive, respectful, unbiased and confidential manner for all I.H.S. Facilities. I.H.S. Headquarters will develop these protocols in consultation with representatives of the Native American community and national groups with expertise in assisting sexual assault survivors. These protocols should be adapted from the Department of Justice’s National Protocol for Sexual Assault Medical Forensic Examinations (available at http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf), with the important addition that all sexual assault survivors be informed about and offered emergency contraception.
b. I.H.S. Facilities shall develop sexual assault treatment services by working in consultation with representatives of the Native American community served by that I.H.S. Facility and with local community groups involved in assisting sexual assault survivors (e.g., rape crisis centers, rape response teams, women’s domestic violence shelters/programs).
c. I.H.S. Facilities shall offer emergency contraception to all survivors of sexual assault and provide such contraception upon request. Providers must document this offer by having each sexual assault survivor sign a form, to be kept in her confidential patient file, acknowledging that she has been offered emergency contraception.
d. I.H.S. Facilities shall provide screening for Sexually Transmitted Infections (STI) and Reproductive Tract Infections (RTI) and shall provide STI treatment and RTI treatment to all survivors of sexual assault.
e. I.H.S. Facilities shall provide testing for HIV and shall inform all rape and incest survivors about PEP (Post-Exposure Prophylaxis).
f. I.H.S. Facilities shall inform all rape and incest survivors that I.H.S. Headquarters provides coverage for abortions where the pregnancy results from rape or incest; document the provision of this information by having each rape and incest survivor sign a form, to be kept in her confidential patient file, acknowledging that she has received this information
V. TRAINING
I.H.S. Facilities shall provide training to all relevant staff regarding the provision of reproductive health care and treatment for sexual assault patients, which includes the following requirements:
a. All I.H.S. Facility service providers shall be appropriately trained to provide services in a culturally acceptable, gender sensitive, respectful, unbiased and confidential manner. This training shall be specific to the Nation/Tribe being served.
b. Trainings shall be revised, updated, and re-administered to all relevant staff as any changes in delivery of services occur and as technological changes occur that would affect a sexual assault survivor or reproductive health patient.
c. Every I.H.S. Facility shall have one Sexual Assault Nurse Examiner or Sexual Assault Forensic Examiner (SANE/SAFE) on staff and/or on call.
d. All I.H.S. Facilities’ medical staff that has occasion to treat sexual assault victims shall be familiar with medical protocol acronyms relevant to such treatment, such as SANE (Sexual Assault Nurse Examiner); SAFE (Sexual Assault Forensic Examiner); SART (Sexual Assault Response Team); Chain of Custody (Protocol followed when working with the Sexual Assault kit.); SOR (Sexual Offense Report – specific to regions hospital); SAER (Sexual Assault Exam Report) and SO/SA (Sexual Offense/Assault).
e. I.H.S. emergency room medical professionals shall administer rape kits on-site without requiring travel or transfer to a contracted facility to perform the rape kit.
f. I.H.S. Facilities shall include current information regarding the provision of information and delivery of reproductive health services and treatment for sexual assault survivors within a staff manual.
g. I.H.S. Facilities shall promptly inform patients and all relevant staff when new reproductive health services or services for sexual assault survivors become available and when coverage of services changes.
h. I.H.S. Facilities shall establish policies, procedures, and protocols for training all relevant staff regarding the provision of information and the delivery of services described under Parts ll and lV above.
VI. DISSEMINATION OF INFORMATION TO PATIENTS AND I.H.S. STAFF
I.H.S. Facilities shall:
a. Inform all patients and relevant staff of what reproductive health services I.H.S. Facilities provide and what reproductive health services I.H.S. Headquarters covers (including, but not limited to abortion, emergency contraception, the full range of FDA-approved contraceptive drugs and devices, services and treatments for survivors of sexual assault.)
b. Amend the Patients’ Bill of Rights to inform women of their right to obtain the full range of FDA – approved contraceptives (including Emergency Contraception), non-directive pregnancy options counseling, PEP and I.H.S. coverage of abortions (surgical and medical) in certain circumstances.
c. Post the amended Patients’ Bill of Rights in every I.H.S. Facility throughout all patient waiting rooms or other areas where patients are regularly received for intake and/or provided care.
d. All policies, procedures, and protocols must be posted and accessible to medical staff, in the emergency room. Emergency room medical personnel shall receive Sexual Assault treatment protocols upon new hire and appropriate training/understanding of protocols. Staff shall be required to review policies, procedures and protocols on a regular basis.
VII. RECORD KEEPING
I.H.S. Facilities shall maintain and report to I.H.S. Headquarters the following data, in a manner that maintains the confidentiality of all patient records and identifying information:
a. The number of women who came in for health services after experiencing incest, rape, or other sexual assault, how many of those women were offered emergency contraception, and how many of those women accepted emergency contraception.
b. The number of women who requested information about an abortion and the number who requested an abortion. For those women who requested an abortion, the number of women who:
i. Received a referral for an abortion;
ii. Had an abortion performed at an I.H.S. Facility;
iii. Sought an abortion because they were pregnant as a result of rape;
iv. Sought an abortion because they were pregnant as a result of incest;
v. Sought an abortion because continuation of the pregnancy endangered their life;
vi. Were Medicaid-eligible and received assistance from an I.H.S. Facility in obtaining an abortion; and
vii. Obtained Medicaid coverage of an abortion.
c. The gender identity of each sexual assault patient.
VIII. REVIEW AND AUDIT
I.H.S. Headquarters shall require all I.H.S. Facilities to establish a review/audit process by which it will ensure that the protocols developed pursuant to the above items are followed at all I.H.S. Facilities. The review/audit process should include, but not be limited to, an evaluation of whether Facilities have kept records or can provide proof to establish that:
a. Patients seeking to prevent pregnancy have received emergency contraception information/prescription;
b. Sexual assault victims have been offered counseling;
c. A sexual assault victim’s advocate was contacted and whether or not she/he was present when a sexual assault patient was treated;
d. The number of sexual assaults presenting annually in the emergency room;
e. Patients have been informed that if a pregnancy resulted from a rape, I.H.S. will provide coverage for an abortion;
f. The number of requests for abortion and/or information requests regarding abortion;
g. The number of abortions provided by an I.H.S. Facility;
h. A SANE/SAFE is in place or on-call at every I.H.S. Facility; and
i. SANE/SAFE training is current and comprehensive and occurs on a yearly basis.