番茄社区

A wider group of providers need to be trained on how to counsel patients regarding contraceptive care, Cynthia Harper, PhD, said Tuesday during a webinar on issues around contraceptive access sponsored by the National Academy of Medicine.

"It is super important to be training a broader set of health providers in primary care -- federally qualified health clinics, school health [providers], emergency departments -- to be able to set up services to offer their patients comprehensive contraceptive care when they come in, because they might not have access to specialty reproductive healthcare in their state," said Harper, a professor of obstetrics, gynecology, and reproductive sciences at the University of California San Francisco (UCSF) School of Medicine.

"Also, now it's really important for us to be teaching providers how to combat misinformation and confusion," she said. "We have a special unit to talk to providers about the science and things like 'Is [emergency contraception] the same as an abortion pill?' -- things that patients still aren't sure about and really can stop patients from using certain options."

The Effect of Dobbs

The Supreme Court's June 2022 decision in the Dobbs v. Jackson Women's Health Organization case overturned a previous decision making abortion legal nationwide. That has left it up to states to regulate abortion, and "I think by now, one and a half years later, we all recognize there are so many areas of overreach in the [wake of the] Dobbs decision -- beyond abortion, into the health professions' and reproductive autonomy and people's overall lives," Harper said.

In particular, "many people in the U.S. don't have equitable access to contraception today, and certainly not to their preferred method," said Harper, whose remarks focused on patients' contraceptive care needs following an abortion. "Among the long-standing challenges in abortion care are specific policies to isolate abortion care from health insurance programs and contraceptive funding programs, so that patients face higher costs for contraception and abortion care."

For example, "funding for both contraception and for abortion through Medicaid can affect a patient's ability to initiate the contraceptive method they selected at abortion care," she said. In addition, "people are relying more on telemedicine abortion, mailed abortion pills, or advance provision [of pills], so they might not have access to contraceptive care while they're having their abortion."

Furthermore, "misinformation, confusion, and stress among the public and providers have shot up post-Dobbs, and it's likely not about to dissipate anytime soon," said Harper. "[One] nurse in an abortion ban state, for example, said, 'I've seen a lot of people bringing in adolescents because they're worried that birth control is going to be outlawed, so they want to get it now.'"

UCSF Pilot Program

Harper said she and her colleagues are implementing a pilot program with the Southwest Contraception Access Network to bring contraceptive care to a set of clinics in states without restrictive abortion laws. "We're doing an experiment serving travel patients as well as in-state patients in these clinics; we're doing on-site training on a full range of [contraceptive] methods," she said. "We're also addressing biases in care, and misinformation and coercion. And we're partnering with abortion funds to provide free access to contraception, including donated supplies ... We also are partnering with a great online pharmacy for travel patients and patients who prefer to get their methods afterwards."

She shared preliminary data from the program, which showed that in terms of offering oral contraceptives (OCs) to abortion patients suffering from migraine headaches with auras, even before the on-site training almost all providers knew that combination OCs were contraindicated in these patients, but only 19% knew that offering progestin-only pills was an option. That number shot up to 100% after the training. Providers also increased their knowledge regarding which contraceptive methods they could offer to gender-expansive patients with ovaries and a uterus who were using testosterone, she said.

On the other hand, contraceptive coercion can also be a problem, said Kavita Shah Arora, MD, MBE, division director for general obstetrics, gynecology, and midwifery at the University of North Carolina at Chapel Hill. In addition to well-known cases of forced sterilization -- such as those reported in the California penal system in 2010 -- "It's really important to remember that this just isn't a case of bad players or awful examples at the margins," she said. "It's also how we conceptualize, implement, and discuss public health strategies that run the risk of being contraceptive coercion -- but more subtle ... and also much more far-reaching."

The Push for LARC

Take, for example, a recent public health push for "LARC [long-acting reversible contraceptive] First" in contraceptive prescribing, she said. "Given that LARCs have superior clinical efficacy, they are long lasting, they're reversible, and they have little room for user error, they have been lauded as first-line contraceptive methods by clinical organizations, nonprofit groups, and public health organizations. There has even been discussion of utilizing rates of the population that use LARC as a measure of the quality of contraceptive care delivered to the population."

However, "patients weigh many factors when making decisions about contraception, not just efficacy or length of use or reversibility," Arora continued. "Other factors like side effects, invasiveness, use of hormones, and permanence are all important factors ... Assuming that there is one best form of contraception across the board for every patient prioritizes public health goals to reduce pregnancy rates and reduce unintended pregnancy rates over an individual patient's goal for their own care."

"I think this is especially true when such efforts are focused on specific sections of the population," she said. "For example, reducing teen pregnancy rates is a commonly discussed public health goal, both domestically across the political spectrum and globally as well. And there are many good reasons for this goal from a public health perspective. But it also sends a message that any adolescent who wants to be pregnant or wants to parent is somehow making a decision outside of medical recommendations, or is inherently bad or inadvisable."

"Taking a step further back, such initiatives also send a message of who we as a society want to parent and who we do not," Arora added. "We don't see public health campaigns promoting greater contraceptive use for married, privately insured 30-year-olds, but we do see these efforts for a variety of marginalized and minoritized groups, such as those with substance use disorder, Native Americans, and patients with Medicaid."

When it comes to shared decision-making regarding contraceptives, "not all shared decision-making is done well," Arora said. "In fact, as most people do it, we actually do it poorly and often reinforce biases and inequities in care as a result." She recommended a three-phase contraceptive counseling discussion between providers and patients: "A 'choice talk,' which involves informing a patient of all the options, including not using a method; then an 'options talk,' where you review a patient's priorities for their own care, and then a 'decision talk,' when you arrive at a decision jointly together."

Comment