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Equity in Reproductive Health

Authors: Hansa Bhargava, MD; Krishna Upadhya, MD, MPH; Meera Shah, MD, MPH, MS; Jane van Dis, MDFaculty and Disclosures


Activity Transcript

Hansa Bhargava: Hello, and welcome to Elevating Health Equity Clinical Advances. I'm Dr Hansa Bhargava, Chief Medical Officer of Medscape Education. I'm very excited today to speak about a very important issue, equity in reproductive healthcare, and we have a wonderful expert panel here, and I'd like to go around the table and have them introduce themselves. Let's start with you, Krishna. Dr Krishna Upadhya. 

Krishna Upadhya: Thank you so much for having me. Yes, I'm Krishna Upadhya. I use she and her pronouns. I'm here. I'm the Vice President for Quality Care and Health Equity at Planned Parenthood Federation of America based in Washington DC. Prior to joining Planned Parenthood, I'm an adolescent medicine specialist, so really, someone who's dedicated my career to focusing on reproductive health for young people, in particular. 

Hansa Bhargava: Thank you very much. Next, let's turn to Dr Jane van Dis. 

Jane van Dis: Hi, I'm Dr Jane van Dis. I'm a Board-Certified OB-GYN. I've been working on issues in reproductive justice for 40 years. I'm an Assistant Professor of OB-GYN at the University of Rochester, and I'm also advisor to Mayday Health, which is an advocacy nonprofit that is getting the word out that women can access abortion pills in all 50 states. 

Hansa Bhargava: Wonderful. Thank you for your work, and lastly and importantly, Dr Meera Shah. 

Meera Shah: I am Dr Meera Shah. I use she, her pronouns. I'm a Board-Certified Family Medicine Physician. I'm the Chief Medical Officer of Planned Parenthood Hudson Peconic in New York. I'm also the Medical Director of Whole Women's Health Alliance in South Bend, Indiana, where I travel to provide abortion care. 

Hansa Bhargava: Thank you. Doctors, thank you so much for taking the time out to have this important discussion. Let's get started. Politics has cast a huge shadow on women's reproductive rights. How has the Dobbs decision, which overturned Roe vs. Wade impacted PPFA? We'll start with you, Krishna, if that's okay. 

Krishna Upadhya: Yeah, happy to speak to that. I think fundamentally, the Dobbs decision, the Supreme Court basically eliminated the constitutional right to abortion across the country, which means that this decision about whether or not to have an abortion is now left up to state-by-state legislatures and politicians, and the real result is chaos and confusion. We know already that doctors across the country, not only those who provide abortion care, but those who provide other services for people, including cancer treatment, treatment for autoimmune disorders like lupus or rheumatoid arthritis, are hesitant to prescribe medications, as an example, including sometimes even pharmacists hesitant to dispense medications because out of fear of potential civil and criminal penalties. I think what's important to remember is that abortion bans don't only affect abortion care specifically, but they really affect the full range of reproductive health services, so we know that we're already seeing in states that have abortion bans, we're seeing reproductive health providers like OB-GYNs, who are relocating potentially to other places because they're really concerned about the risks of just doing their job, and we know that this can ultimately ruin access for a broad range of reproductive health services, and so here at Planned Parenthood, as always, we're really focusing on continuing to provide expert essential healthcare to patients, to advocate, to protect the rights of people, to make decisions about their healthcare, and to really provide education to people to help them live healthy lives. 

Hansa Bhargava: Yeah, the effects are just exponential. Let me turn to Jane here, who is an OB-GYN. What are your thoughts on this, Jane? 

Jane van Dis: Yeah. Well, I actually am in a group of 6,000 OB-GYNs, so I hear their voices day after day after day, and what I will tell you is that they are angry, they are sad, but more so than anything, I think they are morally injured. The idea that they were trained to care for all aspects of women's reproductive health, and in states where it's been outlawed, are now hampered by the legislature for providing the care for women that they know how to do, and that at some points, they are having to wait until the last minute to provide life-saving care. This creates a degree of spiritual and psychological injury, that it's profound, Hansa. It's absolutely profound, but to Krishna's point, yeah, some of them are leaving the state.  

We just saw an article about that earlier this week. They are spending their precious, limited energy, OB-GYN graduates, 85% women into the specialty, many of whom are head of household, many of whom are also mothers, caring for a family, and they're spending their precious, limited time now advocating for basic healthcare for their patients, so it's taking away from their ability to provide for their patients, and coupled with the moral injury, it's exhausting, right? The idea that OB-GYNs would be regulated by laws such as that in Wisconsin, which was written in 1849, we are no longer practicing the medicine of 1849, so the idea that we would be regulated by laws written before much of modern medicine was created is just ... I mean, it absolutely is such a dissonant fracture in the human scientific brain.  

We have medical students that are leaving the state or even the country to get exposure to abortion training. We have residents in OB-GYN who are having to leave their state to obtain this training, at their own expenses, right? The burden and the crushing moral injury of this is beyond what I could have anticipated. 

Hansa Bhargava: So many issues from this one decision, and it's going to have riveting effects, it sounds like, Jane. 

How does this decision affect other aspects of reproductive health? How does the falling of Roe impact other elements of women's reproductive healthcare? 

Meera Shah: Yeah, I wouldn't say that the movement has been ignoring these other issues in the scope of sexual reproductive health, but I will say that the anti-abortion movement has really taken advantage of this opportunity. We hear stories about pharmacists refusing to dispense emergency contraception, people with chronic immune deficiencies or lupus and requiring methotrexate being denied care, patients who have an ectopic pregnancy being denied care, patients who have a compromised pregnancy with ongoing fetal heart tones being denied care, their care being prolonged.  

I myself am pregnant and have refused to go back to my home state, South Carolina, until I was 20 weeks, because I didn't want to be trapped in a situation where I was in trouble. So these issues are really real, and it's caused chaos and it's caused confusion, and it's caused people to not be able to access evidence-based safe medical care that's just tangentially related to abortion itself. 

And so then these organizations and clinics have opened up to maintain access to this critical service, just to keep access alive, and so a lot of them are closing. The Planned Parenthoods and other academic centers and other organizations that have been providing the full scope are still open in the states where abortion is banned. There are other primary care providers, other family docs, other OB/GYNs who really fall prey to the misinformation and to fear of criminalization, and have been cited to delay care, deny care, turn away patients, and we hear and see these stories a lot. 

When Roe fell, we had an uptick in calls from patients seeking long-acting reversible contraception, such as IUDs, because they were concerned about their ability to procure contraception in the future. Folks who were taking the pill, patch, or the ring as their preferred method were considering switching to an IUD or the implantable rod so that they can guarantee access to some method of contraception. I was seeing this in New York and in Indiana. 

Again, there's a lot of confusion around the laws in the state, in the country, and many patients were coming to us saying, "I thought abortion and contraception were both banned in New York, so what do I do?" And so there was so much reassurance and so much discussion around what's legal where and what patients are able to access. I'm also a vasectomist, and so we've definitely seen a rise in patients requesting sterilization, tubal ligation, or vasectomy at our health centers in New York. 

Hansa Bhargava: Krishna, how do we define reproductive rights for women? 

Krishna Upadhya: Yeah, it's great to go back to the basics after hearing from Jane about what's actually happening on the ground. We know that having reproductive rights means having the freedom to manage your own sexual and reproductive health without outside influence and control, and that's really the opposite of what we're seeing right now. I also just want to be really clear that everyone deserves reproductive rights, including the access to the full range of reproductive healthcare services and the quality information that they need to make decisions, and certainly, we know that women are most impacted by this decision, and at the same time, this is not only a decision that affects women, and so I think that's something that it's really important for everyone to keep in mind. As I said earlier, by overturning Roe vs. Wade, the Supreme Court really took these decisions away from people and put them into the hands of legislators by making these restrictions, and it's affecting things like contraception access, access to gender affirming care, access to in vitro fertilization, comprehensive sex education. This really is a decision that has many ripple effects and fundamentally challenges the right that all people should have to make their own decisions about their bodies and manage their sexual health. 

Hansa Bhargava: Great points, Krishna, and I just wanted to ask you, because of your pediatric background, how does this actually affect families? I would just like to ask you specifically about young girls, as well as young boys. 

Krishna Upadhya: Yeah. I think that's a really important question. What we know is that abortion ... There could be young people who need abortion care, and we know that young people, in particular, face unique challenges to getting sexual and reproductive healthcare generally, and abortion, in particular, and so in many states, even before this decision that overturned Roe vs. Wade, young people had a lot of extra barriers and hoops that they would have to go through in order to get abortion care, and certainly, that's continuing and getting worse. I think getting to the issue of families, it's really important to remember that, again, abortion is an issue that really does affect families.  

There's lots of good evidence about how not being able to make the decisions about pregnancy, when to become pregnant, when to not become pregnant, have really long-lasting impacts on not only the person who has the abortion, but the existing children that they probably already have, their partners, their economic outlook for the future, and so it's really important. This is a decision that affects all people, and really, in the field of medicine, it really is something that affects all of medicine, not only ... Certainly, as Jane mentioned, I mean, the moral injury to the people who have been providing abortion care and who continue to do so is devastating, and I think all of us in medicine really need to be paying attention to what those providers need, and also thinking about how we, as a profession, really need to be taking on more responsibility to challenge these decisions because it really does affect all of us. 

Hansa Bhargava: Thank you, Krishna. Let's turn to Meera here for a second. Meera, how do you feel things are changing with self-managed reproductive healthcare, for example, self-managed abortion? 

Meera Shah: Yeah. Self-managed abortion is something that we've been talking about for several years now, not just in the wake of the fall of Roe. The idea that individuals can access mifepristone and misoprostol online is something that is gaining a lot of attention and has become a particular interest. There's been a lot of research to show that sourcing pills from vetted sources on the internet is safe. The issue in terms of equity, that we have with people having to turn to self-managed abortion, is that their ability to make the choice as to how they see their abortion has been compromised, so many people do want to receive abortion care in a brick and mortar building and at a health center, at a clinic, where there's a physician or advanced practice clinician present to provide that abortion care, but in 14 states, that ability to access abortion care in-person has been compromised. 

It's no longer available for most people. There's also been a lot of discussion around how patients are now having to travel, but the reality, Hansa, is that the ability to travel is something that only people of privilege, and mostly white people are able to access. We quickly realized that the majority of the people needing abortion care who are lower-income, people of color, never booked a plane ticket, never traveled outside of the state of their state, never stayed in a hotel, and so there are a lot of navigators and activists, and people working on the ground to help coordinate this transportation for patients who really, really either want an in-clinic abortion procedure or need one because of their gestational age. Otherwise, people are turning to self-managed abortion, meaning, that they're sourcing their pills off of the internet, and we do ... There's a lot of messaging that Planned Parenthood provides around making sure that the information that you gather from the internet, whether it be about contraception, whether it be about abortion is from a vetted source. Our website has plenty of information that patients can access, and so we direct patients there. 

Hansa Bhargava: Yeah, such great points you're making there, Meera, and it is definitely an equity issue, at the very least, from a social economic standpoint. The converse of that is, of course, that those who might be in challenging socioeconomic circumstances will also bear the burden of perhaps not unplanned children, and so there's also ripple effects from a pediatric and family standpoint. Let me turn to Jane here. Jane, do you have any thoughts on this? 

Jane van Dis: Yeah. I just want to add that it is a travesty, as Meera said, that those wishing to access abortion care in brick and mortar situations in 14 states are now limited and had that choice taken away from them. Having said that, it's also important, I think, to look at the data in countries where self-managed abortion was the only way that women have been accessing reproductive healthcare for years, and the fact is, is in America, more than a million women in 2020 had a medication abortion, and only one in 200 had a major complication from that medication abortion, so self-managed medication abortions are safe. One of the things we do at Mayday Health, which is, again, is a non-profit, is like what Meera does at Planned Parenthood, is provide patients information and vetted websites so that they can access the information they need to make a decision for themselves as to whether or not a self-medicated abortion is the right decision for them.  

I think it also is an equity issue, whether or not you have access to broadband, whether or not you're going to be able to find these sites on the internet. That has certain sociodemographic cuts as well, but the fact of the matter is, is that abortion pills are available in all 50 states. It just sometimes, there are some hoops to go through in order to get those pills to you. 

Meera Shah: I also just wanted to add that we've been providing ... I mean, mifepristone was FDA approved in 2000, and we've been providing medication abortion for many, many years now, so this is really about a sourcing issue, and not necessarily about a self-managing issue, in the sense that people historically, had been obtaining the pills from a doctor's office, and now, they're obtaining the pills from a vetted source on the internet, so it's effectively the same thing. It's just being called something a little bit different, so it's really a sourcing issue, because I think that when I'm talking about self-managed abortion, I think that it can oftentimes almost have like a triggering effect to people. It's like, "Oh, wait, people are buying pills off the internet," but if you really look at it, we've been doing this already for a very long time. 

Hansa Bhargava: That's a great point. There is historical context. Krishna, what does the future hold for women's reproductive rights and the impact to equitable healthcare, for example, the effects on maternal mortality rates, critical prenatal care, and overall comprehensive care? 

Krishna Upadhya: Yeah. Unfortunately, we know that the United States already, before June 24th of 2022 had very poor maternal health outcomes relative to other nations that have similar economic capacity, and so it's very concerning about how this decision and all the ripple effects that we've been talking about are going to likely make problems that we have existing, like maternal mortality, maternal morbidity, even worse. I think one thing to keep in mind, there was a recent report from the March of Dimes that showed already that about 36% of counties in the U.S. are already in maternity care deserts, and so those are counties, without any hospitals, providing obstetric care, birthing centers, or practicing OB-GYNs or midwives, so that already affects nearly seven million pregnant people in almost 500,000 births, so when you add the issues around providers, potentially even leaving restricted states because of these added concerns about their ability to provide care, I think I'm definitely concerned about the fact that this decision could worsen existing health inequities related to maternal health. 

Jane van Dis: Yeah, and, Hansa, let's be clear, this law is about misogyny. This law is not about caring about women or families. If that were the case, then to Krishna's point, these legislatures, while taking away a fundamental right to bodily autonomy would've also passed legislation supporting women who then were forced to have a pregnancy and forced to bear children, but they didn't. There's no additional support for pregnant women or for families and children. In fact, the opposite, because many of these states did not expand Medicaid, so their ability to provide for the women and girls in their state is cruel. It's cruel beyond belief. 

Hansa Bhargava: Yeah, and the children. And the children. Absolutely, Jane. How, in terms of what we can do as clinicians, for example, PCPs, or OB-GYNs, or adolescent medicine specialists, how can we best counsel our patients to ensure access to equitable care? Meera, let's start with you. 

Meera Shah: Yeah. I think that first of all, it is requiring a lot of reassurance. The work that I do in New York is very different from the work that I do in Indiana, where I provide abortion care in both states. Indiana banned abortion in September. There was an injunction that was then upheld, so abortion is now legal until January, but to be honest, these laws in the back-and-forth nature of legal banned legal banned is incredibly confusing for patients and causes chaos.

They want people to be confused, they want people to be scared, and fear criminalization so that they don't access care. We've done a lot of work through Planned Parenthood arena, through my work at Whole Women's Health Alliance, and a lot of other organizations, have done a lot of work around reassurance and through social media, through various platforms just to let people know that abortion's legal in certain states, and also, there is self-managed abortion that is available, and there are also many, many navigators out there, helping people get to the care that they need, depending on how far along they are, depending on what their medical history is, Wayfinder Abortion access, Planned Parenthood's website, Whole Women's Health website, I Need An Abortion. is another organization that provides a lot of really up-to-date, high-quality information around where folks can get abortion care. 

Hansa Bhargava: Great. 

Krishna Upadhya: If I could add one- 

Hansa Bhargava: I just ... Yes, please. 

Krishna Upadhya: Oh, I was just going to add one thing to what Meera said, and that is just to emphasize that these are things that we can be doing to support patients, and I think it's super important that we all remember that these are systemic issues and structures that are causing these barriers for patients, and any of us who work for systems, it's our responsibility to really take on the structural issues and really fight them on behalf of patients because, really, we should not be having to leave patients with the responsibility of navigating these barriers that have been set-up that are systemic. 

Hansa Bhargava: Such a great point. On that point, Krishna, I was just going to ask, part of our role, it seems, as clinicians, as physicians has become advocacy, right? On that point, to the three of you, and we are almost at the end of our discussion, I wanted to ask each of you how our audience, if they would like to advocate more, what they can do for this issue that's obviously has so many ramifications across families, across healthcare, across education, and, of course, across the patients who are in these circumstances. 

Meera Shah: I can start- 

Hansa Bhargava: I'll start with you, Krishna. Oh, sure. Sure. Go ahead. 

Krishna Upadhya: Oh, no. 

Meera Shah: Well, one of the things that I always tell people is to recognize that you have a lot of power in the conversations that you have on a day-to-day basis, so talking about abortion among members of your own household, extended family members, and your social networks and professional networks, and don't stop talking about it. Keep talking about it, and talk about what the realities are of it, right? It's no longer a debate. It never was a debate. It's really about the trickle-down effects of what's happening. 

Now, in a post-Roe world, I mean, when Roe was in place, we were seeing inequities across the board that we've been fighting for years, and it's just gotten worse, and encouraging people to stay engaged, continue to talk about it. Abortion is not a bad word. It's a good word, and they should be saying it, talking about it, saying it out loud, not cowering, saying it with a smile. That is the biggest piece of advice that I give people all the time. 

Jane van Dis: I think that one of the most important things we can do is, as Meera says, to talk about it and to make sure that we do not enter a state of learned helplessness, where we are at the mercy of these legislators, so whether that means helping assist people to vote, whether it means getting on social media and telling your story if you've had an abortion, or you had a miscarriage that resulted in an abortion procedure, all these stories matter. 

All these voices matter. We have to fight against a sense that this is inevitable, and that this is going to be the fate in certain states in the U.S., so voting is obviously the key way to do that because these are legislators who did this.  

Hansa Bhargava: Thank you, Jane. Krishna? 

Krishna Upadhya: I think the only piece I will add is I would think from a standpoint of clinical providers, I think it's also important for folks to think about the other systems that they participate in and have privilege around, and those include the institutions that you work for, which we know, unfortunately, too many of our healthcare institutions are afraid to say the word abortion, to Meera's point. I feel strongly as a physician that our profession has allowed this care to become separated from other care as if politicians could just take it away.  

Hansa Bhargava: Absolutely. Well, thank you to the three of you. Such an important issue. A lot of work to be done, a lot of spread of awareness. Also, the resources that you've mentioned are extremely helpful, but also, the importance and responsibility as clinicians to speak up for patients and speak up on these public health issues is now more important than ever. Thank you to the three of you, and thank you for being part of this very important discussion. 

Krishna Upadhya: Thank you so much. 

Jane van Dis: Thank you for having us. 

Meera Shah: Thanks 

This transcript has not been copyedited.

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