Access Issues in Reproductive Health

1. Access Issues in Reproductive Health Meg O’Reilly MD MPH

2. Objectives • Review a range of reasons an individual might have difficulties obtaining a full range of reproductive health care services • Identify “at risk” populations who may have more challenges in obtaining care or services • Discuss cases which will serve as examples of diminished health care access • Develop a framework to think about access issues during the remainder of the course • Consider biases involved in providing reproductive care to women

3. Impediments to Access • Legal • Religious • Rural • Military • Lesbian/Bisexual/Transgender • Poverty • Cultural • Age

4. Resources • www.acog.org • www.guttmacher.org • Making the Grade on Women’s Health: A National and State-By-State Report Card • Special Issues in Women’s Health, ACOG • Ethics in Obstetrics and Gynecology, ACOG • Social Workers and Case Workers at your institution

5. Case 1--Rural • 23 yo G5P3023 who desires contraception. There is only one pharmacy located in her rural town and no other pharmacy within 2 hours. • Her provider writes her a prescription for OCPs. The only pharmacy in town will not fill the prescription due to the pharmacist’s opinions regarding contraception. • Is this “legal”? What are a pharmacist’s responsibilities regarding provision of medications he might be ethically opposed to? What are the patient’s options in this case?

6. Case 1--Rural • 23 yo G5P3023 who desires contraception. There is only one pharmacy located in her rural town and no other pharmacy within 2 hours. • Her MD gives her a prescription for “Plan B” (progesterone only emergency contraception) to use as a backup for condoms. • Is “Plan B” different than regular OCPs? Does the use of “Plan B” induce an abortion? Should a pharmacist have a right to decline a doctor/patient plan for contraception?

7. Case 2--Legal • 21 yo who presents to her health clinic with an unplanned and undesired pregnancy • Her health clinic is a FQHC, the only clinic within 3 hours of her home • What is an FQHC? What are the rules regarding provision of abortion services (or counseling) in clinics who receive funding from federal sources? Does access to medical care always mean access to comprehensive care?

8. Case 2--Legal • 21 yo who presents to her health clinic with an unplanned and undesired pregnancy • Her doctor is a Family Medicine practitioner who does not have training in medical or surgical abortion care • Who can legally provide medical or surgical abortions? Does this have to be an OB/GYN? What percentage of counties in the United States have abortion providers?

9. Case 2--Legal • 21 yo who presents to her health clinic with an unplanned and undesired pregnancy • Her doctor is a member of the state’s Right to Life organization and does not believe in counseling all options • What do you think are the physician’s responsibilities to this patient? Do physicians have to provide comprehensive counseling of all options even if these are counter to strongly held personal beliefs? What is the “law”. What ethical principles are involved?

10. Case 3--Religious • 46 yo who presents to the ED with acute onset of LLQ pain and bleeding. Her pregnancy test is positive. Her hospital is religiously affiliated and has a policy which forbids termination of pregnancy and sterilization procedures. • Her ultrasound reveals a threatened miscarriage. This is an undesired pregnancy and she wishes to proceed with D and C for treatment and concurrent sterilization with tubal ligation. • What is an elective abortion? Is this an elective abortion? Should the patient be able to decide on her ultimate treatment plan? Does a hospital have the responsibility to provide comprehensive treatment options? Should this patient be able to use her anesthesia for a tubal ligation procedure if she were bleeding heavily enough to “need” a D and C? Under what circumstances can this patient be discharged to go to another hospital to get care?

11. Case 3--Religious • 46 yo who presents to the ED with acute onset of LLQ pain and bleeding. Her pregnancy test is positive. Her hospital is religiously affiliated and has a policy which forbids termination of pregnancy and sterilization procedures. • Her ultrasound reveals a left tubal (ectopic) pregnancy with fetal cardiac activity. She wishes to avoid surgery and be treated with methotrexate. • What are her options for treatment? Would use of methotrexate (or surgery) constitute a termination of pregnancy? Does this pregnancy pose a potential risk to the patient? Should she be able to receive treatment for this condition at any hospital?

12. Case 4--Infertility • 35 yo G0 who has a 10 year history of infertility with her current partner. She now has insurance with limited coverage for infertility services. • She makes an appointment for evaluation and is told that she has bilateral tubal obstruction. At the visit, she finds that she will have to pay out of pocket for all of her treatment options. The couple cannot afford the costs of in vitro fertilization. • Should infertility services be covered by insurance? By Medicaid? Is infertility a “disease”. Do some states mandate coverage for infertility treatment? What might be some ramifications of mandated coverage?

13. Case 4--Infertility • 35 yo G0 who has a 10 year history of infertility with her current partner. She now has insurance with limited coverage for infertility services. • The patient and her partner are women in a long term relationship. The clinic is in a conservative community where the REI physician has chosen not to treat same sex couples. • Should infertility services be available for all patients regardless of sexual orientation or other personal characteristics? Does this physician have the right to determine who should “parent”? Does this physician get to decide who he is willing to treat?

14. Case 5--Military • 25 yo female serving in Iraq goes to her military physician • with an undesired pregnancy and requests pregnancy termination • What are the options the military doctor can counsel this patient about? What services can be offered to the patient? What are her options?

15. Case 5--Military • 36 yo female Army officer who presents to her military physician to discuss her amniocentesis results after abnormal ultrasound findings • This is a highly desired pregnancy with a diagnosis of Trisomy 18 • Given that she receives her healthcare in the military, what are her options? • Do you know the usual outcome of Trisomy 18? Would you feel differently about this case if the diagnosis were Trisomy 21?

16. Case 6—L/B/T • 38 yo G1P0, 26 weeks pregnant, presents to the ED with loss of consciousness and concern for stroke. Her partner follows the ambulance and requests to join her for her evaluation and serve as her primary medical decision maker. • Her partner is her husband of 2 years • Will her husband automatically be able to make medical decisions for his wife? Would it be different if he were her unmarried partner?

17. Case 6—L/B/T • 38 yo G1P0, 26 weeks pregnant, presents to the ED with loss of consciousness and concern for stroke. Her partner follows the ambulance and requests to join her for her evaluation and serve as her primary medical decision maker. • Her partner is female and they have been together for 12 years • Will her partner be able to assist this patient with her health care decisions? What documents might help make this a possibility?

18. Case 7--Poverty • 32 yo G2P1011who presents with heavy vaginal bleeding, severe anemia and a finding of uterine fibroids. She has contraindications to medical management and she and her doctor decide on surgical management. • She is a single parent who works as a waitress. She earns just over 200% of the federal poverty level, does not qualify for Medicaid, and has no insurance available through her work. She cannot afford the cost of the surgery. • Is health care a right? Think about this case in the context of the current health care debate. Who pays for her care if she needs emergency surgery?

19. Case 7--Poverty • 32 yo G2P1011who presents with heavy vaginal bleeding, severe anemia and a finding of uterine fibroids. She has contraindications to medical management and she and her doctor decide on surgical management. • She is a Guatemalan citizen, undocumented, who works as a waitress. She cannot afford the cost of the surgery. • What is the difference to access of care for this patient and the prior patient? Do you think this patient has the “right” to receive medical care in the US?

20. Final…and ongoing…questions • Who is at risk for having inadequate access to a full range of reproductive health options? • What are some common reasons that there is limited access to comprehensive care? • Is it okay to have limitations to options? Do limited resources mean that we are required to ration? Will access always be a problem? • How should we as a nation (or state, hospital, clinic, individual health practitioner) decide which services are most important to make available?